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de Havenon A, Ayodele I, Alhanti B, Mac Grory B, Xian Y, Fonarow G, Smith EE, Worrall BB. Prediction of Large Vessel Occlusion Stroke Using Clinical Registries for Research. Neurology 2024; 102:e209424. [PMID: 38759133 PMCID: PMC11175650 DOI: 10.1212/wnl.0000000000209424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 02/23/2024] [Indexed: 05/19/2024] Open
Abstract
OBJECTIVES A reliable method of predicting large vessel occlusion (LVO) stroke in data sets without neuroimaging could be retrospectively applied to expand research efforts. METHODS We conducted a retrospective, cross-sectional cohort analysis of the Get With The Guidelines (GWTG)-Stroke registry. We included adult patients with a final diagnosis of ischemic stroke from 2016 to 2021 who had brain and vascular imaging and excluded those with missing data or posterior circulation stroke. RESULTS We included 416,022 patients of which 125,381 (30.1%) had LVO. The mean age was 71 years, and 48.2% were female. The area under the receiver operating curve (AUC) for the final model, including age, sex, hypertension, dyslipidemia, atrial fibrillation, diabetes, TOAST stroke mechanism, and NIH Stroke Scale (NIHSS), was 0.79 (95% CI 0.79-0.80). Without TOAST mechanism, the AUC was 0.74. The specificity did not exceed 0.5 using different cut points for the NIHSS. DISCUSSION We found that 30% of adult acute ischemic stroke patients in GWTG-Stroke have LVO and that the combination of clinical covariates and NIHSS is only moderately predictive of LVO status. These results are consistent with previous studies and suggest it may not be possible to retrospectively predict LVO with high accuracy in data sets without vascular neuroimaging.
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Affiliation(s)
- Adam de Havenon
- From the Yale University (A.H.), New Haven, CT; Duke Clinical Research Institute (I.A., B.A.), Durham; Duke University (B.M.G.), Durham, NC; UT-Southwestern Medical Center (Y.X.), Dallas, TX; University of California Los Angeles (G.F.); University of Calgary (E.E.S.), Canada; University of Virginia (B.B.W.), Charlottesville, VA
| | - Iyanuoluwa Ayodele
- From the Yale University (A.H.), New Haven, CT; Duke Clinical Research Institute (I.A., B.A.), Durham; Duke University (B.M.G.), Durham, NC; UT-Southwestern Medical Center (Y.X.), Dallas, TX; University of California Los Angeles (G.F.); University of Calgary (E.E.S.), Canada; University of Virginia (B.B.W.), Charlottesville, VA
| | - Brooke Alhanti
- From the Yale University (A.H.), New Haven, CT; Duke Clinical Research Institute (I.A., B.A.), Durham; Duke University (B.M.G.), Durham, NC; UT-Southwestern Medical Center (Y.X.), Dallas, TX; University of California Los Angeles (G.F.); University of Calgary (E.E.S.), Canada; University of Virginia (B.B.W.), Charlottesville, VA
| | - Brian Mac Grory
- From the Yale University (A.H.), New Haven, CT; Duke Clinical Research Institute (I.A., B.A.), Durham; Duke University (B.M.G.), Durham, NC; UT-Southwestern Medical Center (Y.X.), Dallas, TX; University of California Los Angeles (G.F.); University of Calgary (E.E.S.), Canada; University of Virginia (B.B.W.), Charlottesville, VA
| | - Ying Xian
- From the Yale University (A.H.), New Haven, CT; Duke Clinical Research Institute (I.A., B.A.), Durham; Duke University (B.M.G.), Durham, NC; UT-Southwestern Medical Center (Y.X.), Dallas, TX; University of California Los Angeles (G.F.); University of Calgary (E.E.S.), Canada; University of Virginia (B.B.W.), Charlottesville, VA
| | - Gregg Fonarow
- From the Yale University (A.H.), New Haven, CT; Duke Clinical Research Institute (I.A., B.A.), Durham; Duke University (B.M.G.), Durham, NC; UT-Southwestern Medical Center (Y.X.), Dallas, TX; University of California Los Angeles (G.F.); University of Calgary (E.E.S.), Canada; University of Virginia (B.B.W.), Charlottesville, VA
| | - Eric E Smith
- From the Yale University (A.H.), New Haven, CT; Duke Clinical Research Institute (I.A., B.A.), Durham; Duke University (B.M.G.), Durham, NC; UT-Southwestern Medical Center (Y.X.), Dallas, TX; University of California Los Angeles (G.F.); University of Calgary (E.E.S.), Canada; University of Virginia (B.B.W.), Charlottesville, VA
| | - Bradford B Worrall
- From the Yale University (A.H.), New Haven, CT; Duke Clinical Research Institute (I.A., B.A.), Durham; Duke University (B.M.G.), Durham, NC; UT-Southwestern Medical Center (Y.X.), Dallas, TX; University of California Los Angeles (G.F.); University of Calgary (E.E.S.), Canada; University of Virginia (B.B.W.), Charlottesville, VA
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Regenhardt RW, Nolan NM, Das AS, Mahajan R, Monk AD, LaRose SL, Migdady I, Chen Y, Sheriff F, Bai X, Dmytriw AA, Patel AB, Snider SB, Vaitkevicius H. Transcranial Doppler cerebrovascular reactivity: Thresholds for clinical significance in cerebrovascular disease. J Neuroimaging 2024; 34:348-355. [PMID: 38553906 DOI: 10.1111/jon.13197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/04/2024] [Accepted: 03/07/2024] [Indexed: 05/14/2024] Open
Abstract
BACKGROUND AND PURPOSE Thresholds for abnormal transcranial Doppler cerebrovascular reactivity (CVR) studies are poorly understood, especially for patients with cerebrovascular disease. Using a real-world cohort with cerebral arterial stenosis, we sought to describe a clinically significant threshold for carbon dioxide reactivity (CO2R) and vasomotor range (VMR). METHODS CVR studies were performed during conditions of breathing room air normally, breathing 8% carbon dioxide air mixture, and hyperventilation. The mean and standard deviation (SD) of CO2R and VMR were calculated for the unaffected side in patients with unilateral stenosis; a deviation of 2 SDs below the mean was chosen as the threshold for abnormal. Receiver operating characteristic (ROC) curves for both sides for patients with unilateral and bilateral stenosis were evaluated for sensitivity (Sn) and specificity (Sp). RESULTS A total of 133 consecutive CVR studies were performed on 62 patients with stenosis with mean±SD age 55±16 years. Comorbidities included hypertension (60%), diabetes (15%), stroke (40%), and smoking (35%). In patients with unilateral stenosis, mean±SD CO2R for the unaffected side was 1.86±0.53%, defining abnormal CO2R as <0.80%. Mean±SD CO2R for the affected side was 1.27±0.90%. The CO2R threshold predicted abnormal acetazolamide single-photon emission computed tomography (SPECT) (Sn = .73, Sp = .79), CT/MRI perfusion abnormality (Sn = .42, Sp = .77), infarction on MRI (Sn = .45, Sp = .76), and pressure-dependent exam (Sn = .50, Sp = .76). For the unaffected side, mean±SD VMR was 39.5±15.8%, defining abnormal VMR as <7.9%. For the affected side, mean±SD VMR was 26.5±17.8%. The VMR threshold predicted abnormal acetazolamide SPECT (Sn = .46, Sp = .94), infarction on MRI (Sn = .27, Sp = .94), and pressure-dependent exam (Sn = .31, Sp = .90). CONCLUSIONS In patients with multiple vascular risk factors, a reasonable threshold for clinically significant abnormal CO2R is <0.80% and VMR is <7.9%. Noninvasive CVR may aid in diagnosing and risk stratifying patients with stenosis.
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Affiliation(s)
- Robert W Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Neal M Nolan
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alvin S Das
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Rahul Mahajan
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew D Monk
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- NovaSignal, Los Angeles, California, USA
| | - Sarah L LaRose
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ibrahim Migdady
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Neurocritical Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Yimin Chen
- Department of Neurology, Foshan Sanshui District People's Hospital, Foshan, China
| | - Faheem Sheriff
- Department of Neurology, Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine, El Paso, Texas, USA
| | - Xuesong Bai
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Adam A Dmytriw
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Samuel B Snider
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Henrikas Vaitkevicius
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Status Epilepticus Division, Marinus Pharmaceuticals, Radnor, Pennsylvania, USA
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Zhou R, Wei C, Zhao M, Sun L. Association between short-term glucose fluctuations and cognition in patients with acute ischemic stroke complicated by type 2 diabetes mellitus. J Nutr Health Aging 2024; 28:100252. [PMID: 38692207 DOI: 10.1016/j.jnha.2024.100252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 03/11/2024] [Accepted: 04/17/2024] [Indexed: 05/03/2024]
Abstract
OBJECTIVES Glucose fluctuations are more harmful than persistent hyperglycemia for chronic complications of diabetes. However, the relationship between cognition and glucose fluctuations in patients with acute ischemic stroke (AIS) complicated by type 2 diabetes mellitus (T2DM) remains unclear. We aimed to evaluate the association between short-term glucose fluctuations and cognition in patients with AIS complicated by T2DM. DESIGN A cohort study with a 2-year follow-up. SETTING AND PARTICIPANTS We included 554 patients with mild AIS (mean age: 62 years; 170 females and 384 males). MEASUREMENTS Glucose variability (GV) was evaluated using glycated hemoglobin (HbA1c), stress hyperglycemia (SHR), standard deviation of blood glucose (SDBG), mean postprandial blood glucose (MPBG), mean amplitude of glycemic excursion (MAGE), and time in range (TIR). We evaluated the relationship between GV, fasting blood glucose (FBG) and cognition during the acute phase using linear regression analysis. We evaluated the relationship between GV, FBG and the occurrence of post-stroke cognitive impairment (PSCI) using a logistic regression model. Mediation analyses were fitted to explore whether the relationships of HbA1c with cognition were mediated by cerebral small vessel disease (CSVD). RESULTS A clear pattern of age-related GV was observed. Higher SHR in middle-aged participants; higher HbA1c, and lower TIR in older participants; and higher MAGE, MPBG, and SDBG across a broad age range (50-80 years) were associated with cognitive impairment in the acute phase of AIS. Higher SHR and SDBG together with lower TIR in middle-aged participants, higher HbA1c in older participants, and higher FBG, MPBG, and MAGE across a broad age range (50-80 years) were associated with the occurrence of PSCI. The association between HbA1c and cognition was partially mediated (proportion: 7-16%) by CSVD. CONCLUSIONS Short-term glucose fluctuations are associated with cognition and a higher risk of PSCI in patients with AIS complicated by T2DM. CSVD might play an important role in the relationship between short-term glucose fluctuations and cognition.
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Affiliation(s)
- Ruolin Zhou
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Jilin University, Changchun, China; Cognitive Center, Department of Neurology, The First Hospital of Jilin University, Jilin University, Changchun, China
| | - Chunxiao Wei
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Jilin University, Changchun, China; Cognitive Center, Department of Neurology, The First Hospital of Jilin University, Jilin University, Changchun, China
| | - Meng Zhao
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Jilin University, Changchun, China; Cognitive Center, Department of Neurology, The First Hospital of Jilin University, Jilin University, Changchun, China
| | - Li Sun
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Jilin University, Changchun, China; Cognitive Center, Department of Neurology, The First Hospital of Jilin University, Jilin University, Changchun, China.
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Jung JW, Kim KH, Yun J, Kim YD, Heo J, Lee H, Choi JK, Lee IH, Lim IH, Hong SH, Kim BM, Kim DJ, Shin NY, Cho BH, Ahn SH, Park H, Sohn SI, Hong JH, Song TJ, Chang Y, Kim GS, Seo KD, Lee K, Chang JY, Seo JH, Lee S, Baek JH, Cho HJ, Shin DH, Kim J, Yoo J, Baik M, Lee KY, Jung YH, Hwang YH, Kim CK, Kim JG, Lee CJ, Park S, Jeon S, Lee HS, Kwon SU, Bang OY, Heo JH, Nam HS. Functional Outcomes Associated With Blood Pressure Decrease After Endovascular Thrombectomy. JAMA Netw Open 2024; 7:e246878. [PMID: 38630474 PMCID: PMC11024769 DOI: 10.1001/jamanetworkopen.2024.6878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 02/19/2024] [Indexed: 04/19/2024] Open
Abstract
Importance The associations between blood pressure (BP) decreases induced by medication and functional outcomes in patients with successful endovascular thrombectomy remain uncertain. Objective To evaluate whether BP reductions induced by intravenous BP medications are associated with poor functional outcomes at 3 months. Design, Setting, and Participants This cohort study was a post hoc analysis of the Outcome in Patients Treated With Intra-Arterial Thrombectomy-Optimal Blood Pressure Control trial, a comparison of intensive and conventional BP management during the 24 hours after successful recanalization from June 18, 2020, to November 28, 2022. This study included 302 patients who underwent endovascular thrombectomy, achieved successful recanalization, and exhibited elevated BP within 2 hours of successful recanalization at 19 stroke centers in South Korea. Exposure A BP decrease was defined as at least 1 event of systolic BP less than 100 mm Hg. Patients were divided into medication-induced BP decrease (MIBD), spontaneous BP decrease (SpBD), and no BP decrease (NoBD) groups. Main Outcomes and Measures The primary outcome was a modified Rankin scale score of 0 to 2 at 3 months, indicating functional independence. Primary safety outcomes were symptomatic intracerebral hemorrhage within 36 hours and mortality due to index stroke within 3 months. Results Of the 302 patients (median [IQR] age, 75 [66-82] years; 180 [59.6%] men), 47 (15.6%)were in the MIBD group, 39 (12.9%) were in the SpBD group, and 216 (71.5%) were in the NoBD group. After adjustment for confounders, the MIBD group exhibited a significantly smaller proportion of patients with functional independence at 3 months compared with the NoBD group (adjusted odds ratio [AOR], 0.45; 95% CI, 0.20-0.98). There was no significant difference in functional independence between the SpBD and NoBD groups (AOR, 1.41; 95% CI, 0.58-3.49). Compared with the NoBD group, the MIBD group demonstrated higher odds of mortality within 3 months (AOR, 5.15; 95% CI, 1.42-19.4). The incidence of symptomatic intracerebral hemorrhage was not significantly different among the groups (MIBD vs NoBD: AOR, 1.89; 95% CI, 0.54-5.88; SpBD vs NoBD: AOR, 2.75; 95% CI, 0.76-9.46). Conclusions and Relevance In this cohort study of patients with successful endovascular thrombectomy after stroke, MIBD within 24 hours after successful recanalization was associated with poor outcomes at 3 months. These findings suggested lowering systolic BP to below 100 mm Hg using BP medication might be harmful.
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Affiliation(s)
- Jae Wook Jung
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Kwang Hyun Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Jaeseob Yun
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - JoonNyung Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Hyungwoo Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Kyo Choi
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Il Hyung Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - In Hwan Lim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Soon-Ho Hong
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Moon Kim
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Joon Kim
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Na Young Shin
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Bang-Hoon Cho
- Department of Neurology, Korea University Anam Hospital and College of Medicine, Seoul, Korea
| | - Seong Hwan Ahn
- Department of Neurology, Chosun University School of Medicine, Gwangju, Korea
| | - Hyungjong Park
- Department of Neurology, Brain Research Institute, Keimyung University School of Medicine, Daegu, Korea
| | - Sung-Il Sohn
- Department of Neurology, Brain Research Institute, Keimyung University School of Medicine, Daegu, Korea
| | - Jeong-Ho Hong
- Department of Neurology, Brain Research Institute, Keimyung University School of Medicine, Daegu, Korea
| | - Tae-Jin Song
- Department of Neurology, Seoul Hospital, Ewha Woman's University, College of Medicine, Seoul, Korea
| | - Yoonkyung Chang
- Department of Neurology, Mokdong Hospital, Ewha Woman's University College of Medicine, Seoul, Korea
| | - Gyu Sik Kim
- National Health Insurance Service, Ilsan Hospital, Goyang, Korea
| | - Kwon-Duk Seo
- National Health Insurance Service, Ilsan Hospital, Goyang, Korea
| | - Kijeong Lee
- National Health Insurance Service, Ilsan Hospital, Goyang, Korea
| | - Jun Young Chang
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Hwa Seo
- Department of Neurology, Busan Paik Hospital, Inje University College of Medicine, Busan, South Korea
| | - Sukyoon Lee
- Department of Neurology, Busan Paik Hospital, Inje University College of Medicine, Busan, South Korea
| | - Jang-Hyun Baek
- Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Han-Jin Cho
- Department of Neurology, Pusan National University School of Medicine, Busan, Korea
| | - Dong Hoon Shin
- Department of Neurology, Gachon University Gil Medical Center, Incheon, Korea
| | - Jinkwon Kim
- Department of Neurology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Joonsang Yoo
- Department of Neurology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Minyoul Baik
- Department of Neurology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Kyung-Yul Lee
- Department of Neurology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yo Han Jung
- Department of Neurology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yang-Ha Hwang
- Department of Neurology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Chi Kyung Kim
- Department of Neurology, Korea University Guro Hospital and College of Medicine, Seoul, Korea
| | - Jae Guk Kim
- Department of Neurology, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejon, Korea
| | - Chan Joo Lee
- Department of Health Promotion, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sungha Park
- Department of Health Promotion, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
- Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Soyoung Jeon
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Sun Lee
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Sun U Kwon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
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Wang H, Guo Y, Xu J, Sun Y, Ji Y, Xu X, Yang Q, Huang X, Zhou Z. Blood pressure variability and outcome in atherosclerosis versus cardioembolism cerebral large vessel occlusion after successful thrombectomy. Hypertens Res 2024; 47:898-909. [PMID: 37978233 DOI: 10.1038/s41440-023-01500-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 10/18/2023] [Accepted: 10/20/2023] [Indexed: 11/19/2023]
Abstract
Higher blood pressure variability (BPV) has been proven associated with worse functional outcome after endovascular treatment (EVT). However, this association is not established according to different stroke etiologies. In this study, we compared patients with the two highest proportions of stroke etiologies-cardioembolism (CE) and large-artery atherosclerosis (LAA), aiming to explore appropriate strategies of BP management for different etiologies. We enrolled patients with large vessel occlusion (LVO) in anterior circulation who underwent EVT and achieved successful recanalization retrospectively. 24-h blood pressure (BP) and BPV measured as blood pressure reduction (BPr), standard deviation (SD), coefficient of variation (CV), successive variation (SV), average real variability (ARV) after EVT were collected for systolic blood pressure (SBP) and diastolic blood pressure (DBP). The favorable outcome was defined as functional independence by 90-day modified Rankin Scale (mRS 0-2). In our cohort, higher BPV parameters significantly resulted in 90d functional dependence in CE-LVO patients (SBPSV OR: 1.083, 95%CI = 1.009-1.163; SBPARV OR: 1.121, 95%CI = 1.019-1.233; DBPSD OR: 1.124, 95%CI = 1.007-1.1256; DBPCV OR: 1.078, 95%CI = 1.002-1.161). However, for LAA-LVO patients, no positive results correlated 90d functional dependence with 24-hour BPV. Additionally, 90d functional dependence in CE patients with poor collaterals were significantly dependent on post-procedural BPV (DBPmax OR: 1.044, 95%CI = 1.002-1.087; DBPSD OR: 1.229, 95%CI = 1.022-1.1.479; DBPCV OR: 1.143, 95%CI = 1.009-1.295). Whereas to patients with good collaterals, there did not exist such a correlation. In summary, stroke etiologies should probably be taken into consideration to optimize individualized BP management strategies. In order to achieve better clinical outcomes for patients with acute ischemic stroke due to large vessel occlusion, stricter blood pressure management should be taken in cardioembolic stroke patients in contrast with large artery atherosclerotic stroke patients after successful endovascular therapy.
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Affiliation(s)
- Hao Wang
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Yapeng Guo
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Junfeng Xu
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Yi Sun
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Yachen Ji
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Xiangjun Xu
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Qian Yang
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Xianjun Huang
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China.
| | - Zhiming Zhou
- Department of Neurology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China.
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Abuelazm M, Khildj Y, Ibrahim AA, Mahmoud A, Amin AM, Gowaily I, Khan U, Abdelazeem B, Brašić JR. Intensive Blood Pressure Control After Endovascular Thrombectomy for Acute Ischemic Stroke: a Systematic Review and Meta-Analysis. Clin Neuroradiol 2024:10.1007/s00062-024-01391-6. [PMID: 38453701 DOI: 10.1007/s00062-024-01391-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 01/22/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND AND PURPOSE Optimal clinical outcome with successful recanalization from endovascular thrombectomy (EVT) requires optimal blood pressure (BP) management. We aimed to evaluate the efficacy and safety of the intensive BP target (< 140 mm Hg) versus the standard BP target (< 180 mm Hg) after EVT for acute ischemic stroke. METHODS We conducted a systematic review and meta-analysis synthesizing evidence from randomized controlled trials (RCTs) obtained from PubMed, Embase Cochrane, Scopus, and WOS until September 7th, 2023. We used the fixed-effect model to report dichotomous outcomes using risk ratio (RR) and continuous outcomes using mean difference (MD), with a 95% confidence interval (CI). PROSPERO ID CRD42023463206. RESULTS We included four RCTs with 1559 patients. There was no difference between intensive BP and standard BP targets regarding the National Institutes of Health Stroke Scale (NIHSS) change after 24 h [MD: 0.44 with 95% CI (0.0, 0.87), P = 0.05]. However, the intensive BP target was significantly associated with a decreased risk of excellent neurological recovery (mRS ≤ 1) [RR: 0.87 with 95% CI (0.76, 0.99), P = 0.03], functional independence (mRS ≤ 2) [RR: 0.81 with 95% CI (0.73, 0.90), P = 0.0001] and independent ambulation (mRS ≤ 3) [RR: 0.85 with 95% CI (0.79, 0.92), P < 0.0001]. CONCLUSIONS An intensive BP target after EVT is associated with worse neurological recovery and significantly decreased rates of functional independence and independent ambulation compared to the standard BP target. Therefore, the intensive BP target should be avoided after EVT for acute ischemic stroke.
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Affiliation(s)
| | - Yehya Khildj
- Faculty of Medicine, University of Algiers, Algiers, Algeria
| | | | | | | | | | - Ubaid Khan
- Faculty of Medicine, King Edward Medical University, Lahore, Pakistan
| | - Basel Abdelazeem
- Department of Cardiology, West Virginia University, West Virginia, USA
| | - James Robert Brašić
- Section of High-Resolution Brain Positron Emission Tomography Imaging, Division of Nuclear Medicine and Molecular Imaging, The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Behavioral Health, New York City Health and Hospitals/Bellevue, New York, NY, USA
- Department of Psychiatry, New York University Grossman School of Medicine, New York University Langone Health, New York, NY, USA
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Ommati MM, Rezaei H, Socorro RM, Tian W, Zhao J, Rouhani A, Sabouri S, Ghaderi F, Niknahad AM, Najibi A, Mazloomi S, Safipour M, Honarpishefard Z, Wang HW, Niknahad H, Heidari R. Pre/postnatal taurine supplementation improves neurodevelopment and brain function in mice offspring: A persistent developmental study from puberty to maturity. Life Sci 2024; 336:122284. [PMID: 38008208 DOI: 10.1016/j.lfs.2023.122284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 11/17/2023] [Accepted: 11/20/2023] [Indexed: 11/28/2023]
Abstract
Taurine (TAU) is a sulfur-containing amino acid abundantly found in the human body. Endogenously, TAU is synthesized from cysteine in the liver. However, newborns rely entirely on TAU's dietary supply (milk). There is no investigation on the effect of long-term TAU administration on next-generation neurological development. The current study evaluated the effect of long-term TAU supplementation during the maternal gestational and litter weaning time on several neurological parameters in mice offspring. Moreover, the effects of TAU on mitochondrial function and oxidative stress biomarkers as plausible mechanisms of its action in the whole brain and hippocampus have been evaluated. TAU (0.5 % and 1 % w/v) was dissolved in the drinking water of pregnant mice (Day one of pregnancy), and amino acid supplementation was continued during the weaning time (post-natal day; PND = 21) until litters maturity (PND = 65). It was found that TAU significantly improved cognitive function, memory performance, reflexive motor activity, and emotional behaviors in F1-mice generation. TAU measurement in the brain and hippocampus revealed higher levels of this amino acid. TAU and ATP levels were also significantly higher in the mitochondria isolated from the whole brain and hippocampus. Based on these data, TAU could be suggested as a supplement during pregnancy or in pediatric formula. The effects of TAU on cellular mitochondrial function and energy metabolism might play a fundamental role in the positive effects of this amino acid observed in this investigation.
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Affiliation(s)
- Mohammad Mehdi Ommati
- Henan Key Laboratory of Environmental and Animal Product Safety, College of Animal Science and Technology, Henan University of Science and Technology, Luoyang 471000, Henan, China; Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Heresh Rezaei
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Department of Pharmacology and Toxicology, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Retana-Márquez Socorro
- Department of Reproductive Biology, Universidad Autónoma Metropolitana-Iztapalapa, México City, Mexico
| | - Weishun Tian
- Henan Key Laboratory of Environmental and Animal Product Safety, College of Animal Science and Technology, Henan University of Science and Technology, Luoyang 471000, Henan, China
| | - Jing Zhao
- Henan Key Laboratory of Environmental and Animal Product Safety, College of Animal Science and Technology, Henan University of Science and Technology, Luoyang 471000, Henan, China
| | - Ayeh Rouhani
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Samira Sabouri
- Henan Key Laboratory of Environmental and Animal Product Safety, College of Animal Science and Technology, Henan University of Science and Technology, Luoyang 471000, Henan, China; College of Animal Science and Veterinary, Shanxi agricultural University, Taigu, Shanxi, China
| | - Fatemeh Ghaderi
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amir Mohammad Niknahad
- Department of Pharmacology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Asma Najibi
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Department of Pharmacology and Toxicology, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran; Department of Chemistry and Biochemistry, Miami University, 244 Hughes Laboratories, 651 E. High Street, Oxford, OH 45056, USA
| | - Sahra Mazloomi
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Moslem Safipour
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zahra Honarpishefard
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hong-Wei Wang
- Henan Key Laboratory of Environmental and Animal Product Safety, College of Animal Science and Technology, Henan University of Science and Technology, Luoyang 471000, Henan, China.
| | - Hossein Niknahad
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Department of Reproductive Biology, Universidad Autónoma Metropolitana-Iztapalapa, México City, Mexico.
| | - Reza Heidari
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
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Migdady I, Johnson-Black PH, Leslie-Mazwi T, Malhotra R. Current and Emerging Endovascular and Neurocritical Care Management Strategies in Large-Core Ischemic Stroke. J Clin Med 2023; 12:6641. [PMID: 37892779 PMCID: PMC10607145 DOI: 10.3390/jcm12206641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 10/17/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023] Open
Abstract
The volume of infarcted tissue in patients with ischemic stroke is consistently associated with increased morbidity and mortality. Initial studies of endovascular thrombectomy for large-vessel occlusion excluded patients with established large-core infarcts, even when large volumes of salvageable brain tissue were present, due to the high risk of hemorrhagic transformation and reperfusion injury. However, recent retrospective and prospective studies have shown improved outcomes with endovascular thrombectomy, and several clinical trials were recently published to evaluate the efficacy of endovascular management of patients presenting with large-core infarcts. With or without thrombectomy, patients with large-core infarcts remain at high risk of in-hospital complications such as hemorrhagic transformation, malignant cerebral edema, seizures, and others. Expert neurocritical care management is necessary to optimize blood pressure control, mitigate secondary brain injury, manage cerebral edema and elevated intracranial pressure, and implement various neuroprotective measures. Herein, we present an overview of the current and emerging evidence pertaining to endovascular treatment for large-core infarcts, recent advances in neurocritical care strategies, and their impact on optimizing patient outcomes.
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Affiliation(s)
- Ibrahim Migdady
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurological Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, NY 10032, USA
| | - Phoebe H. Johnson-Black
- Department of Neurosurgery, Division of Neurocritical Care, UCLA David Geffen School of Medicine, Ronald Reagan Medical Center, Los Angeles, CA 90095, USA;
| | | | - Rishi Malhotra
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurological Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
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Al-Tawil M, Salem M, Friedrich C, Diraz S, Broll A, Rezahie N, Schoettler J, de Silva N, Puehler T, Cremer J, Haneya A. Preoperative Imaging Signs of Cerebral Malperfusion in Acute Type A Aortic Dissection: Influence on Outcomes and Prognostic Implications-A 20-Year Experience. J Clin Med 2023; 12:6659. [PMID: 37892797 PMCID: PMC10607191 DOI: 10.3390/jcm12206659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 10/11/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Acute type A aortic dissection (ATAAD) continues to be a subject of active research due to its high mortality rates and associated complications. Cerebral malperfusion in ATAAD can have a devastating impact on patients' neurological function and overall quality of life. We aimed to explore the risk profile and prognosis in ATAAD patients presenting with preoperative imaging signs of cerebral malperfusion (PSCM). METHODS We obtained patient data from our Aortic Dissection Registry, which included 480 consecutive ATAAD cases who underwent surgical repair between 2001 and 2021. Primary endpoint outcomes included the in-hospital and 30-day mortality, postoperative new neurological deficit, mechanical ventilation hours, and intensive care unit (ICU) length of stay. RESULTS Of the total cohort, 82 patients (17.1%) had PSCM. Both groups had similar distributions in terms of age, sex, and body mass index. The patients in the PSCM group presented with a higher logistic EuroSCORE (47, IQR [31, 64] vs. 24, IQR [15, 39]; p < 0.001) and a higher portion of patients with a previous cardiac surgery (7.3% vs. 2.0%; p = 0.020). Intraoperatively, the bypass, cardioplegia, and aortic cross-clamp times were similar between both groups. However, the patients in the PSCM group received significantly more intraoperative packed red blood cells, fresh frozen plasma, and platelets transfusions (p < 0.05). Following the surgery, the patients who presented with PSCM had markedly longer ventilation hours (108.5 h, IQR [44, 277] vs. 43 h, IQR [16, 158], p < 0.001) and a significantly longer ICU length of stay (7 days, IQR [4, 13] vs. 5 days, IQR [2, 11]; p = 0.013). Additionally, the patients with PSCM had significantly higher rates of postoperative new neurological deficits (35.4% vs. 19.4%; p = 0.002). In the Cox regression analysis, PSCM was associated with significantly poorer long-term survival (hazard ratio (HR) 1.75, 95%CI [1.20-2.53], p = 0.003). Surprisingly, hypertension was shown as a protective factor against long-term mortality (HR: 0.59, 95%CI [0.43-0.82], p = 0.001). CONCLUSION PSCM in ATAAD patients is linked to worse postoperative outcomes and poorer long-term survival, emphasizing the need for early recognition and tailored management.
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Anadani M, Maier B, Escalard S, Labreuche J, de Havenon A, Sabben C, Lapergue B, Mistry EA, Gory B, Spiotta AM, Richard S, Sibon I, Desilles JP, Blanc R, Piotin M, Mazighi M. Safety and efficacy of intensive systolic blood pressure lowering after successful endovascular therapy: a post hoc analysis of the BP TARGET trial. J Neurointerv Surg 2023; 15:e142-e147. [PMID: 36220337 DOI: 10.1136/jnis-2022-019130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 08/28/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND The Safety and Efficacy of Intensive Blood Pressure Lowering after Successful Endovascular Therapy in Acute Ischaemic Stroke (BP TARGET) trial demonstrated no benefit from intensive systolic blood pressure (SBP) treatment after successful reperfusion with endovascular therapy. However, it remains unknown if the response to blood pressure treatment is modified by other factors. OBJECTIVE To carry out a post hoc analysis of the BP TARGET trial data to determine if the response to blood pressure treatment is modified by factors such as age, history of hypertension, recanalization status, location of occlusion, diabetes, hyperglycemia, or pretreatment with intravenous thrombolysis. METHODS This is a post hoc analysis of the BP TARGET trial. Patients were divided into groups based on age, diabetes, blood glucose, site of occlusion, history of hypertension, and pretreatment with intravenous thrombolysis. The primary outcome was any intraparenchymal hemorrhage. RESULTS 318 patients were included. Diabetes modified the treatment effect on favorable functional outcome (Pheteogenity=0.041). There was a trend towards benefit from intensive SBP treatment in diabetic patients (OR=2.81; 95% CI 0.88 to 8.88; p=0.08) but not in non-diabetic patients (OR=0.75; 95% 0.45 to 126; p 0.28). Age, location of occlusion, admission SBP, pretreatment with intravenous thrombolysis, and history of hypertension did not modify the effect of intensive SBP treatment on any of the outcomes. CONCLUSION The effect of SBP lowering treatment was not modified by age, location of occlusion history of hypertension, intravenous thrombolysis, and admission SBP. Diabetes modified the effect of intensive SBP lowering treatment, and there was a trend towards benefit from intensive SBP treatment in diabetic patients. This finding is hypothesis generating and requires further validation.
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Affiliation(s)
- Mohammad Anadani
- Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - Benjamin Maier
- Department of Interventional Neuroradiology, Adolphe de Rothschild Ophthalmological Foundation, Paris, France
| | - Simon Escalard
- Departement of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France
| | | | - Adam de Havenon
- Department of Neurology, Yale University, New Haven, Connecticut, USA
| | - Candice Sabben
- Department of Neurology, Fondation Rothschild Hospital, paris, France
| | | | - Eva A Mistry
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Benjamin Gory
- Department of Diagnostic and Interventional Neuroradiology, CHRU Nancy, Nancy, Lorraine, France
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Sébastien Richard
- Neurology Stroke Unit, University Hospital Centre Nancy, Nancy, France
| | | | | | - Raphael Blanc
- Department of Interventional Neuroradiology, Fondation Rothschild, Paris, Île-de-France, France
| | - Michel Piotin
- Departement of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France
| | - Mikaël Mazighi
- Departement of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France
- Department of Neurology, GH Lariboisiere Fernand-Widal, Paris, France
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11
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Zhou Y, Chen Z, Fang J, Huang G. Blood pressure targets for acute ischemic stroke patients following endovascular thrombectomy: A meta-analysis. Clin Neurol Neurosurg 2023; 231:107835. [PMID: 37354634 DOI: 10.1016/j.clineuro.2023.107835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 06/09/2023] [Accepted: 06/10/2023] [Indexed: 06/26/2023]
Abstract
OBJECTIVE The objective of this meta-analysis was to explore the impact of different blood pressure levels following endovascular therapy on clinical outcomes, including safety and efficacy in acute ischemic stroke (AIS) patients. METHODS A systematic search was performed on PubMed, Embase, Cochrane Library, and Web of Science databases, covering studies published before February 1, 2023. Our primary outcomes were 90-day mRs 0-2 score, 90-day mortality, incidence of symptomatic intracranial hemorrhage(sICH), and hemicraniectomy. RESULTS The incidence of 90-day mRs= 2 score was no significant difference between different blood pressure values (OR=1.37, 95 % CI [0.82, 2.29], p = 0.23) with heterogeneity (I2 =85 %, p < 0.001). Subgroup analysis indicated that when the blood pressure targets were SBP< 140 mmHg (OR=1.73, 95 % CI [1.04, 2.90], p = 0.04) with heterogeneity (I2 =37 %, p = 0.20), and SBP< 130 mmHg (OR=1.58, 95 % CI [0.53, 4.70], p = 0.41) with heterogeneity (I2 =80 %, p = 0.02), there were statistic differences in the incidence of 90-day modified mRs 0-2 score. Regarding 90-day mortality, there was no significant difference between different blood pressure values (OR=0.75, 95 % CI [0.47, 1.21], p = 0.24; I2 =69 %, p = 0.007). As for the incidence of sICH, the difference was not statistically significant (OR = 0.82, 95 % CI [0.61, 1.09], p = 0.17; I2 =24 %, p = 0.26). However, subgroup analysis was performed due to different blood pressure values, and it was found that when the blood pressure targets were SBP<140 mmHg (OR=0.49, 95 % CI [0.28, 0.87], p = 0.02) and SBP<120 mmHg (OR = 0.84, 95 % CI [0.58, 1.23], p = 0.37), there were statistic differences in the incidence of sICH with SBP<140 mmHg. Furthermore, SBP<140 mmHg was associated with a lower incidence of hemicraniectomy (OR = 0.30, 95 % CI [0.15, 0.58], p<0.001). PROSPERO Register Number: CRD42022376706 CONCLUSION: The present meta-analysis findings indicate that intensive treatment is advantageous for achieving successful reperfusion in acute ischemic stroke (AIS) patients undergoing endovascular therapy (EVT). For different blood pressure targets (SBP < 140mmhg, SBP < 130mmhg, SBP < 120mmhg), with a reduction in systolic blood pressure (SBP) to less than 140 mmHg appearing to confer the greatest benefit. Furthermore, this study provides a significant blood pressure target that could inform the design of future multicentre, open-label, blinded-endpoint, randomized controlled trials.
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Affiliation(s)
- Yitao Zhou
- School of Nursing, Zhejiang Chinese Medical University, Hangzhou City, Zhejiang Province, China
| | - Zixi Chen
- Department of Emergency Medcine, the Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou City, China
| | - Jinyan Fang
- Department of Emergency Medcine, the Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou City, China
| | - Ganying Huang
- Department of Emergency Medcine, the Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou City, China.
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Tang Y, Dong Z, Wang N, Del Aguila A, Johnston N, Vu T, Ma C, Xu Y, Yang W, Song P, Yao J. Non-invasive Deep-Brain Imaging with 3D Integrated Photoacoustic Tomography and Ultrasound Localization Microscopy (3D-PAULM). ARXIV 2023:arXiv:2307.14572v1. [PMID: 37547654 PMCID: PMC10402205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Photoacoustic computed tomography (PACT) is a proven technology for imaging hemodynamics in deep brain of small animal models. PACT is inherently compatible with ultrasound (US) imaging, providing complementary contrast mechanisms. While PACT can quantify the brain's oxygen saturation of hemoglobin (sO2), US imaging can probe the blood flow based on the Doppler effect. Further, by tracking gas-filled microbubbles, ultrasound localization microscopy (ULM) can map the blood flow velocity with sub-diffraction spatial resolution. In this work, we present a 3D deep-brain imaging system that seamlessly integrates PACT and ULM into a single device, 3D-PAULM. Using a low ultrasound frequency of 4 MHz, 3D-PAULM is capable of imaging the whole-brain hemodynamic functions with intact scalp and skull in a totally non-invasive manner. Using 3D-PAULM, we studied the mouse brain functions with ischemic stroke. Multi-spectral PACT, US B-mode imaging, microbubble-enhanced power Doppler (PD), and ULM were performed on the same mouse brain with intrinsic image co-registration. From the multi-modality measurements, we future quantified blood perfusion, sO2, vessel density, and flow velocity of the mouse brain, showing stroke-induced ischemia, hypoxia, and reduced blood flow. We expect that 3D-PAULM can find broad applications in studying deep brain functions on small animal models.
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Affiliation(s)
- Yuqi Tang
- Department of Biomedical Engineering, Duke University, Durham, NC 27703 USA
| | - Zhijie Dong
- Beckman Institute for Advanced Science and Technology and the Department of Electrical and Computer Engineering, University of Illinois Urbana-Champaign, Urbana, IL 61801 USA
| | - Nanchao Wang
- Department of Biomedical Engineering, Duke University, Durham, NC 27703 USA
| | - Angela Del Aguila
- Brain Protection Program, Department of Anesthesiology, School of Medicine, Duke University, Durham 27710, NC, USA
| | - Natalie Johnston
- Department of Biomedical Engineering, Duke University, Durham, NC 27703 USA
| | - Tri Vu
- Department of Biomedical Engineering, Duke University, Durham, NC 27703 USA
| | - Chenshuo Ma
- Department of Biomedical Engineering, Duke University, Durham, NC 27703 USA
| | - Yirui Xu
- Department of Biomedical Engineering, Duke University, Durham, NC 27703 USA
| | - Wei Yang
- Brain Protection Program, Department of Anesthesiology, School of Medicine, Duke University, Durham 27710, NC, USA
| | - Pengfei Song
- Beckman Institute for Advanced Science and Technology and the Department of Electrical and Computer Engineering, University of Illinois Urbana-Champaign, Urbana, IL 61801 USA
| | - Junjie Yao
- Department of Biomedical Engineering, Duke University, Durham, NC 27703 USA
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Regenhardt RW, Potter CA, Huang SS, Lev MH. Advanced Imaging for Acute Stroke Treatment Selection: CT, CTA, CT Perfusion, and MR Imaging. Radiol Clin North Am 2023; 61:445-456. [PMID: 36931761 DOI: 10.1016/j.rcl.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
There is constant evolution in the diagnosis and treatment of acute ischemic stroke due to advances in treatments, imaging, and outreach. Two major revolutions were the advent of intravenous thrombolysis in the 1990s and endovascular thrombectomy in 2010s. Neuroimaging approaches have also evolved with key goals-detect hemorrhage, augment thrombolysis treatment selection, detect arterial occlusion, estimate infarct core, estimate viable penumbra, and augment thrombectomy treatment selection. The ideal approach to diagnosis and treatment may differ depending on the system of care and available resources. Future directions include expanding indications for these treatments, including a shift from time-based to tissue-based selection.
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Affiliation(s)
- Robert W Regenhardt
- Massachusetts General Hospital, 55 Fruit Street, WAC 7-745, Boston, MA 02114, USA. https://twitter.com/rwregen
| | | | - Samuel S Huang
- Albany Medical College, 438 Waltham Street, Lexington, MA 02421, USA
| | - Michael H Lev
- Massachusetts General Hospital, 55 Fruit Street, WAC 7-745, Boston, MA 02114, USA
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14
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Hu M, Zhu Y, Chen Z, Li W, Li L, Li Y, Xia Y, Zhang T, Feng Q, Wu J, Wu M. Relationship between mean blood pressure during hospitalization and clinical outcome after acute ischemic stroke. BMC Neurol 2023; 23:156. [PMID: 37081452 PMCID: PMC10116692 DOI: 10.1186/s12883-023-03209-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 04/14/2023] [Indexed: 04/22/2023] Open
Abstract
OBJECTIVE The optimal blood pressure (BP) targets for acute ischemic stroke are unclear. We aimed to assess the relationship between Mean BP and clinical outcomes during hospitalization. MATERIALS AND METHODS We included 649 patients with Acute ischemic stroke (AIS) from December 2020 to July 2021. BP was measured daily, and mean blood pressure was calculated. Clinical events recorded within 90 days of randomization were: recurrent ischemic stroke, symptomatic intracranial hemorrhage, and death. The modified Rankin Scale (mRS) was used to measure primary outcomes 3 months after AIS. Logistic multiple regression analysis was performed by statistical software R. RESULT There is a nonlinear U-shaped relationship between SBP and poor outcomes. This means higher SBP and lower SBP will increase the incidence of poor outcomes. The optimal mean SBP during hospitalization was 135-150 mmHg, and patients with SBP < 135mmhg OR 2.4 [95% Cl, (1.16 ~ 4.97)], P = 0.018; and > 150mmhg OR 2.04 [95% Cl, 1.02 ~ 4.08], p = 0.045 had a higher probability of poor outcomes. CONCLUSION Our study shows that the optimal SBP of patients with AIS during hospitalization was 135-150 mmHg. The findings suggest that the relationship between mean SBP and 3-month functional outcome after AIS was U-shaped. Both higher SBP and lower SBP lead to poor prognosis in AIS patients.
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Affiliation(s)
- Manyan Hu
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Yuan Zhu
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Zhaoyao Chen
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Wenlei Li
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Li Li
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Yunze Li
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Yangjingyi Xia
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Tianrui Zhang
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Qinghua Feng
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Jiacheng Wu
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China
| | - Minghua Wu
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, 155 Hanzhong Road, Nanjing, 210029, China.
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15
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Li H, Li M, Dong S, Dong A, Wang J, Zhu Y, Deng Y, Chen S, Zhang M. Preliminary study of the interactive effects of coronary heart disease and lacunar infarction on renal function in patients with type 2 diabetes mellitus by gender. J Diabetes Complications 2023; 37:108477. [PMID: 37121118 DOI: 10.1016/j.jdiacomp.2023.108477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 04/10/2023] [Accepted: 04/11/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Coronary heart disease (CHD) and lacunar infarction (LI) are the most common cardio- cerebrovascular complications of type 2 diabetes mellitus (T2DM) and a recognized risk factor for renal injury. Although a unidirectional association of CHD or LI with T2DM or the kidney has been demonstrated, however, it remains unknown whether there is an interactive effect of the coexistence of CHD and LI on renal function in T2DM patients. The aim of our study was to investigate the interaction between CHD and LI on renal function in gender-specific patients with T2DM and the association between cardio-cerebrovascular disease-related conventional serum markers and the estimated glomerular filtration rate (eGFR). METHODS We conducted a cross-sectional study in Beijing and Tianjin from April 2019 to August 2021. Participants with T2DM aged ≥18 years were asked to complete a one-to-one questionnaire and physical examination. RESULTS In this study, 389 eligible patients with T2DM were included, with a mean age of 63.04 ± 9.41 years, of whom 200 (51.41 %) were male. The proportions of patients with CHD, LI, and both CHD and LI were 28.53 %, 24.42 %, and 11.05 %, respectively. Compared to T2DM patients without either CHD or LI, those with both CHD and LI were found to have a significantly greater risk of reduced eGFR (OR: 12.82, 95 % CI 5.06-32.52, P < 0.001) than those with CHD alone (OR: 2.42, 95 % CI 1.37-3.00, P = 0.004) or LI alone (OR: 1.15, 95 % CI 0.61-2.18, P = 0.664). The combined presence of CHD and LI is associated with a significantly greater risk of decreased eGFR in female T2DM patients compared to their male counterparts. We found both multiplicative and additive effects in all T2DM patients; however, when stratified by sex, only multiplicative effects were observed. After controlling for interference from CHD, LI, and age, we found that total cholesterol (TC) was negatively correlated with eGFR in females (r = -0.156, P = 0.034), and low-density lipoprotein cholesterol (LDL-C) was negatively correlated with eGFR in males (r = -0.229, P = 0.001). CONCLUSION This study provides novel evidence that the synergistic effect of CHD and LI on renal injury in patients with T2DM is significantly greater than their individual effects. Women with T2DM who have both CHD and LI are at a 4.85-fold higher risk of decreased eGFR than men. Therefore, increased clinical attention should be given to preventing and treating vascular complications in T2DM patients, as well as aggressively reducing lipid levels, particularly TC and LDL-C, to delay or prevent renal dysfunction in T2DM patients.
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Affiliation(s)
- Hongdian Li
- Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Mingxuan Li
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Shaoning Dong
- Tianjin Academy of Traditional Chinese Medicine Affiliated Hospital, Tianjin, China
| | - Ao Dong
- Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Jing Wang
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yuanyuan Zhu
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yuanyuan Deng
- Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Shu Chen
- Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Mianzhi Zhang
- Dongfang Hospital, Beijing University of Chinese Medicine, Beijing, China; Tianjin Academy of Traditional Chinese Medicine Affiliated Hospital, Tianjin, China.
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Nuerlanbieke H, Niyazi A, Wu Q, Yuan Y, Habudele Z, Dun X, Wei R, Aisha A. Efficacy of modified EDAS combined with a superficial temporal fascia attachment-dural reversal surgery for the precise treatment of ischemic cerebrovascular disease. Front Surg 2023; 10:1087311. [PMID: 37066009 PMCID: PMC10090302 DOI: 10.3389/fsurg.2023.1087311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 02/15/2023] [Indexed: 03/31/2023] Open
Abstract
ObjectiveTo investigate the potential therapeutic benefits of Modified EDAS combined with superficial temporal fascia attachment-dural reversal surgery for the treatment of ischemic cerebrovascular disease.MethodsRetrospective analysis was made on the clinical data of 33 patients with ischemic cerebrovascular disease, who were admitted to the Neurological Diagnosis and Treatment Center of the Second Affiliated Hospital of Xinjiang Medical University from December 2019 to June 2021. All patients were treated with Modified EDAS combined with superficial temporal fascia attachment-dural reversal surgery. At 3 months after operation, the outpatient department rechecked the patient's head CT perfusion imaging (CTP) to understand the intracranial cerebral blood flow perfusion. The DSA of the patient's head was re-examined 6 months after operation to observe the establishment of collateral circulation. The improved Rankin Rating Scale (mRS) score was used to evaluate the good prognosis rate of patients at 6 months after surgery. The mRS score ≤2 was defined as good prognosis.ResultsThe preoperative cerebral blood flow (CBF), local blood flow peak time (rTTP), and local mean transit time (rMTT) of 33 patients were 28.235 ml/(100 g·min), 17.702 s, 9.796 s, respectively. At 3 months after surgery, CBF, rTTP, and rMTT were 33.743 ml/(100 g·min), 15.688, and 8.100 s, respectively, with significant differences (P < 0.05). At 6 months after operation, the establishment of extracranial and extracranial collateral circulation was observed in all patients by re-examination of head DSA. At 6 months after operation, the good prognosis rate was 81.8%.ConclusionThe Modified EDAS combined with superficial temporal fascia attachment-dural reversal surgery is safe and effective in the treatment of ischemic cerebrovascular disease, which can significantly increase the establishment of collateral circulation in the operation area and improve the prognosis of patients.
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Affiliation(s)
- Hanati Nuerlanbieke
- Department of Neurosurgery, The 2th Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Ailiyaer Niyazi
- Department of Neurosurgery, The 2th Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Qinfen Wu
- Department of Neurosurgery, The 2th Affiliated Hospital of Xinjiang Medical University, Urumqi, China
- Xinjiang Key Laboratory of Neurological Disorder Research, Urumqi, China
- Correspondence: Qinfen Wu Yang Yuan
| | - Yang Yuan
- Department of Neurosurgery, The 2th Affiliated Hospital of Xinjiang Medical University, Urumqi, China
- Xinjiang Key Laboratory of Neurological Disorder Research, Urumqi, China
- Correspondence: Qinfen Wu Yang Yuan
| | - Zanghaer Habudele
- Xinjiang Key Laboratory of Neurological Disorder Research, Urumqi, China
| | - Xiaoyi Dun
- Xinjiang Medical University, Urumqi, China
| | - RuRui Wei
- Department of Neurosurgery, The 2th Affiliated Hospital of Xinjiang Medical University, Urumqi, China
- Xinjiang Key Laboratory of Neurological Disorder Research, Urumqi, China
| | - Abudula Aisha
- Department of Neurosurgery, The 2th Affiliated Hospital of Xinjiang Medical University, Urumqi, China
- Xinjiang Key Laboratory of Neurological Disorder Research, Urumqi, China
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17
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Wang H, Liu H, Jiang Q, You S, Guo Z, Hou J, Xiao G. Prognostic significance of blood pressure parameters after mechanical thrombectomy according to collateral status. BMC Neurol 2023; 23:123. [PMID: 36978000 PMCID: PMC10044781 DOI: 10.1186/s12883-023-03160-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 03/13/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Mechanical thrombectomy (MT) has been proven as an effective and safe therapy for patients with acute ischemic stroke from large vessel occlusion. However, there is still a controversial topic about post-procedural management including blood pressure (BP). METHODS A total of 294 patients who received MT in Second Affiliated Hospital of Soochow University from April 2017 to September 2021 were included consecutively. The association of blood pressure parameters (BPV and hypotension time) with poor functional outcome was evaluated using logistic regression models. Meanwhile, the effects of BP parameters on mortality was analyzed using cox proportional hazards regression models. Furthermore, the corresponding multiplicative term was added to the above models to study the interaction between BP parameters and CS. RESULTS Two hundred ninety four patients were included finally. The mean age was 65.5 years. At the 3-month follow-up, 187(61.5%) had poor functional outcome and 70(23.0%) died. Regardless of the CS, BP CV is positively associated with poor outcome. Hypotension time was negatively associated with poor outcome. We conducted a subgroup analysis according to CS. BPV was significantly associated with mortality at 3-month and displayed a trend toward poor outcome for patients with poor CS only. The interaction between SBP CV and CS with respect to mortality after adjusting for confounding factors was statistically significant (P for interaction = 0.025) and the interaction between MAP CV and CS with respect to mortality after multivariate adjustment was also statistically significant (P for interaction = 0.005). CONCLUSION In MT-treated stroke patients, higher BPV in the first 72 h is significantly associated with poor functional outcome and mortality at 3-month regardless of CS. This association was also found for hypotension time. Further analysis showed CS modified the association between BPV and clinical prognosis. BPV displayed a trend toward poor outcome for patients with poor CS.
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Affiliation(s)
- Huaishun Wang
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, the Second Affiliated Hospital of Soochow University, No. 1055 Sanxiang Road, Suzhou, 215004, China
| | - Huihui Liu
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, the Second Affiliated Hospital of Soochow University, No. 1055 Sanxiang Road, Suzhou, 215004, China
| | - Qianmei Jiang
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, the Second Affiliated Hospital of Soochow University, No. 1055 Sanxiang Road, Suzhou, 215004, China
| | - Shoujiang You
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, the Second Affiliated Hospital of Soochow University, No. 1055 Sanxiang Road, Suzhou, 215004, China
| | - Zhiliang Guo
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, the Second Affiliated Hospital of Soochow University, No. 1055 Sanxiang Road, Suzhou, 215004, China
| | - Jie Hou
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, the Second Affiliated Hospital of Soochow University, No. 1055 Sanxiang Road, Suzhou, 215004, China
| | - Guodong Xiao
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, the Second Affiliated Hospital of Soochow University, No. 1055 Sanxiang Road, Suzhou, 215004, China.
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18
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Meng QZ, Wang Y, Li B, Xi Z, Wang M, Xiu JQ, Yang XP. Relationship between glycemic variability and cognitive function in lacune patients with type 2 diabetes. World J Clin Cases 2023; 11:1019-1030. [PMID: 36874411 PMCID: PMC9979288 DOI: 10.12998/wjcc.v11.i5.1019] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/26/2022] [Accepted: 01/10/2023] [Indexed: 02/14/2023] Open
Abstract
BACKGROUND Lacunes are the manifestations of lacunar infarction which can lead many patients to the clinical outcome of disability or dementia. However, the relationship between lacune burden, cognitive function and blood glucose fluctuation in patients with type 2 diabetes mellitus (T2DM) complicated with lacunes is not very clear.
AIM To explore the correlation between glucose variability, lacune burden and cognitive function in patients with lacunes complicated with T2DM.
METHODS The clinical and imaging data of 144 patients with lacunes combined with T2DM were reviewed retrospectively. 72 h continuous glucose monitoring was performed. The Montreal Cognitive Assessment was used to assess cognitive function. The burden of lacunes was evaluated using magnetic resonance imaging performance. Multifactorial logistic regression analysis was used to study the affecting the lacune load and cognitive impairment in patients. To predict the value of patients' cognitive impairment with lacunes complicated with T2DM, a receiver operating characteristic (ROC) curve and a nomogram prediction model were constructed.
RESULTS The standard deviation (SD) of the average blood glucose concentration, percentage coefficient of variation (%CV) and time of range (TIR) were significantly different between the low and the high load groups (P < 0.05). The SD, %CV and TIR of the cognitive impairment group and non-cognitive impairment group were significantly different (P < 0.05). SD (odds ratio (OR): 3.558, 95% confidence interval (CI): 1.268-9.978, P = 0.006), and %CV (OR: 1.192, 95%CI: 1.081-1.315, P < 0.05) were the risk factors for an increased infarct burden in lacunes patients complicated with T2DM. TIR (OR: 0.874, 95%CI: 0.833-0.928, P < 0.05) is a protective factor. In addition, an increased SD (OR: 2.506, 95%CI: 1.008-6.23, P = 0.003), %CV (OR: 1.163, 95%CI: 1.065-1.270, P < 0.05) were the risk factors for cognitive impairment in patients with lacunes complicated with T2DM, TIR (OR: 0.957, 95%CI: 0.922-0.994, P < 0.05) is a protective factor. A nomogram prediction model of the risk of cognitive impairment was established based on SD, %CV and TIR. Decision curve analysis and the internal calibration analysis were used for internal verification and showed that the model was clinical benefit. The area under the ROC curves for predicting cognitive impairment in patients with lacunes complicated with T2DM was drawn were %CV: 0.757 (95%CI :0.669-0.845, P < 0.05), TIR: 0.711 (95%CI: 0.623-0.799, P < 0.05).
CONCLUSION Blood glucose variability is closely associated with the level of lacune burden and cognitive dysfunction in lacune patients combined with T2DM. %CV, TIR have a certain predictive effect in cognitive impairment in lacune patients.
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Affiliation(s)
- Qi-Zhe Meng
- Department of Neurology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou 450003, Henan Province, China
| | - Yang Wang
- Department of Neurology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou 450003, Henan Province, China
| | - Bing Li
- Department of Neurology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou 450003, Henan Province, China
| | - Zhi Xi
- Department of Neurology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou 450003, Henan Province, China
| | - Ming Wang
- Department of Neurology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou 450003, Henan Province, China
| | - Jia-Qi Xiu
- Department of Neurology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou 450003, Henan Province, China
| | - Xiao-Peng Yang
- Department of Neurology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou 450003, Henan Province, China
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Percent Insular Ribbon Infarction for Predicting Infarct Growth Rate and 90-Day Outcomes in Large-Vessel Occlusive Stroke: Secondary Analysis of Prospective Clinical Trial Data. AJR Am J Roentgenol 2023:1-11. [PMID: 36790114 DOI: 10.2214/ajr.22.28852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Background: Insight into the natural history of infarct growth could help identify patients with slowly progressing stroke who may benefit from delayed endovascular thrombectomy (EVT). Objective: To evaluate associations of percent insular ribbon infarction (PIRI) with infarct growth rate (IGR) and 90-day outcomes in patients with large-vessel occlusion (LVO) stroke. Methods: This retrospective study was a secondary analysis of a prior clinical trial that enrolled patients with acute stroke not treated with reperfusion therapies from January 2007 to June 2009. The present analysis evaluated 31 trial patients (median age, 71 years; 12 female, 19 male) with anterior-circulation LVO who underwent serial MRI examinations. Two neuroradiologists independently scored PIRI on presentation MRI examinations based on the ratio of the length of the portion of the insula showing restricted diffusion to the insula's total length using a previously described 0-4 scale; scores were categorized [mild (0-1), moderate (2), or severe (3-4)], and discrepancies were resolved by consensus. Ninety-day modified Rankin Scale (mRS) was obtained. As part of earlier clinical trial analysis, collateral pattern on CTA was classified (symmetric, malignant, other), and infarct volumes were measured on DWI during the initial 48 hours after presentation and on FLAIR at 90 days. Results: Inter-rater agreement for PIRI category was strong (K=0.890). PIRI was mild in 10, moderate in 4, and severe in 17 patients. For mild, moderate, and severe PIRI, median onset-to-presentation IGR was 1.6, 8.5, and 17.5 cc/h (p<.001); median presentation-to-48-hour IGR was 0.3, 0.2, and 1.2 cc/h (p=.005); median 90-day infarct volume was 9.4, 39.8, and 108.6 cc (p=0.01); 90-day mRS ≤2 occurred in 78%, 67%, and 6% of patients (p=.001). In multivariable models controlling for age, ICA occlusion, and collateral pattern, PIRI category independently predicted onset-to-presentation IGR (β=1.5), presentation-to-48-hour IGR (β=1.3), and 90-day mRS ≤2 (OR=0.2). For predicting 90-day mRS ≤2, mild-to-moderate PIRI had sensitivity of 90.0% and specificity of 84.2%; symmetric collateral pattern had sensitivity of 70.0% and specificity of 73.7%. Conclusion: PIRI was independently associated with IGR and 90-day outcome. Clinical Impact: PIRI may help identify patients who could benefit from late-window EVT when requiring transfer to EVT-capable centers.
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20
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Regenhardt RW, Lev MH, He J, Dmytriw AA, Vranic JE, Rabinov JD, Stapleton CJ, Patel AB, Singhal AB, Gonzalez RG. Symmetric collateral pattern on CTA predicts favorable outcomes after endovascular thrombectomy for large vessel occlusion stroke. PLoS One 2023; 18:e0284260. [PMID: 37141234 PMCID: PMC10159158 DOI: 10.1371/journal.pone.0284260] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 03/27/2023] [Indexed: 05/05/2023] Open
Abstract
Endovascular thrombectomy (EVT) has revolutionized large vessel occlusion (LVO) stroke management, but often requires advanced imaging. The collateral pattern on CT angiograms may be an alternative because a symmetric collateral pattern correlates with a slowly growing, small ischemic core. We tested the hypothesis that such patients will have favorable outcomes after EVT. Consecutive patients (n = 74) with anterior LVOs who underwent EVT were retrospectively analyzed. Inclusion criteria were available CTA and 90-day modified Rankin Scale (mRS). CTA collateral patterns were symmetric in 36%, malignant in 24%, or other in 39%. Median NIHSS was 11 for symmetric, 18 for malignant, and 19 for other (p = 0.02). Ninety-day mRS ≤2, indicating independent living, was achieved in 67% of symmetric, 17% of malignant, and 38% of other patterns (p = 0.003). A symmetric collateral pattern was a significant determinant of 90-day mRS ≤2 (aOR = 6.62, 95%CI = 2.24,19.53; p = 0.001) in a multivariable model that included age, NIHSS, baseline mRS, thrombolysis, LVO location, and successful reperfusion. We conclude that a symmetric collateral pattern predicts favorable outcomes after EVT for LVO stroke. Because the pattern also marks slow ischemic core growth, patients with symmetric collaterals may be suitable for transfer for thrombectomy. A malignant collateral pattern is associated with poor clinical outcomes.
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Affiliation(s)
- Robert W Regenhardt
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Michael H Lev
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Julian He
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Adam A Dmytriw
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Justin E Vranic
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - James D Rabinov
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Christopher J Stapleton
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Aneesh B Singhal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - R Gilberto Gonzalez
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
- Athinoula A Martinos Center for Biomedical Imaging, Boston, MA, United States of America
- Mass General Brigham Data Science Office, Boston, MA, United States of America
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21
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Impact of leukoaraiosis or blood pressure on clinical outcome, mortality and symptomatic intracerebral hemorrhage after mechanical thrombectomy in acute ischemic stroke. Sci Rep 2022; 12:21750. [PMID: 36526650 PMCID: PMC9758212 DOI: 10.1038/s41598-022-25171-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 11/25/2022] [Indexed: 12/23/2022] Open
Abstract
We aimed to study the impact of leukoaraiosis (LA) and blood pressure (BP) on clinical outcome, mortality and symptomatic intracerebral hemorrhage (sICH) in acute ischemic stroke (AIS) patients treated with mechanical thrombectomy (MT). We analyzed data retrospectively from 521 patients with anterior large vessel occlusion treated with MT. LA was dichotomized in 0-2 (absent-to-moderate) versus 3-4 (moderate-to-severe) according to the van Swieten scale. Various systolic (SBP) and diastolic (DBP) BP parameters during the first 24 h were collected. Multivariable logistic regressions were performed to identify predictors of a poor 90-day outcome, mortality and sICH. LA was significantly associated with poor outcome (OR 3.2; p < 0.001) and mortality (OR 3.19; p = 0.008), but not sICH (p = 0.19). Higher maximum SBP was significantly associated with poor outcome (OR per 10 mmHg increase = 1.21; p = 0.009) and lower mean DBP was a predictor of mortality (OR per 10 mmHg increase = 0.53; p < 0.001). In the univariate analysis high SBP variability was associated with poor outcome, mortality and sICH, but not in the multivariate model. There was no association between BP and sICH. Severity of LA, SBP variability, high maximum SBP and low DBP are associated with either poor outcome or mortality in AIS patients undergoing MT. However, neither LA nor BP were associated with sICH in our cohort. Thus, mechanisms of the negative impact on outcome remain unclear. Further studies on impact of BP course and its mechanisms and interventions are needed to improve outcome in patients undergoing MT.
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22
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Regenhardt RW, Nolan NM, Rosenthal JA, McIntyre JA, Bretzner M, Bonkhoff AK, Snider SB, Das AS, Alotaibi NM, Vranic JE, Dmytriw AA, Stapleton CJ, Patel AB, Rost NS, Leslie-Mazwi TM. Understanding Delays in MRI-based Selection of Large Vessel Occlusion Stroke Patients for Endovascular Thrombectomy. Clin Neuroradiol 2022; 32:979-986. [PMID: 35486123 DOI: 10.1007/s00062-022-01165-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 03/25/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE Given the efficacy of endovascular thrombectomy (EVT), optimizing systems of delivery is crucial. Magnetic resonance imaging (MRI) is the gold standard for evaluating tissue viability but may require more time to obtain and interpret. We sought to identify determinants of arrival-to-puncture time for patients who underwent MRI-based EVT selection in a real-world setting. METHODS Patients were identified from a prospectively maintained database from 2011-2019 that included demographics, presentations, treatments, and outcomes. Process times were obtained from the medical charts. MRI times were obtained from time stamps on the first sequence. Linear and logistic regressions were used to infer explanatory variables of arrival-to-puncture times and effects of arrival-to-puncture time on functional outcomes. RESULTS In this study 192 patients (median age 70 years, 57% women, 12% non-white) underwent MRI-based EVT selection. 66% also underwent computed tomography (CT) at the hub before EVT. General anesthesia was used for 33%. Among the entire cohort, the median arrival-to-puncture was 102 min; however, among those without CT it was 77 min. Longer arrival-to-puncture times independently reduced the odds of 90-day good outcome (∆mRS ≤ 2 from pre-stroke, aOR = 0.990, 95%CI = 0.981-0.999, p = 0.040) when controlling for age, NIHSS, and good reperfusion (TICI 2b-3). Independent determinants of longer arrival-to-puncture were CT plus MRI (β = 0.205, p = 0.003), non-white race/ethnicity (β = 0.162, p = 0.012), coronary disease (β = 0.205, p = 0.001), and general anesthesia (β = 0.364, p < 0.0001). CONCLUSION Minimizing arrival-to-puncture time is important for outcomes. Real-world challenges exist in an MRI-based EVT selection protocol; avoiding double imaging is key to saving time. Racial/ethnic disparities require further study. Understanding variables associated with delay will inform protocol changes.
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Affiliation(s)
- Robert W Regenhardt
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA, 02114.
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA, 02114.
| | - Neal M Nolan
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA, 02114
| | - Joseph A Rosenthal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA, 02114
| | - Joyce A McIntyre
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA, 02114
| | - Martin Bretzner
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA, 02114
| | - Anna K Bonkhoff
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA, 02114
| | - Samuel B Snider
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA, 02114
| | - Alvin S Das
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA, 02114
| | - Naif M Alotaibi
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA, 02114
| | - Justin E Vranic
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA, 02114
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA, 02114
| | - Adam A Dmytriw
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA, 02114
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA, 02114
| | - Christopher J Stapleton
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA, 02114
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA, 02114
| | - Natalia S Rost
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA, 02114
| | - Thabele M Leslie-Mazwi
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA, 02114
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA, 02114
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23
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Chong CZ, Tan BYQ, Sia CH, Khaing T, Litt Yeo LL. Simultaneous cardiocerebral infarctions: a five-year retrospective case series reviewing natural history. Singapore Med J 2022; 63:686-690. [PMID: 33866711 DOI: 10.11622/smedj.2021043] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Introduction Concurrent cardiocerebral infarction (CCI), a rare condition defined as simultaneous occlusions in the cerebrovascular and coronary vessels, has high mortality but very limited literature on optimum treatment methods. A better understanding of the natural history and effect of treatment would improve patient outcomes. Methods Using our prospective stroke database from 2014 to 2018, ten consecutive patients with CCI were identified (incidence = 0.29%). We recorded patient demographics, cardiovascular risk factors, cardiac and cerebral occlusions, circumstances of admission and management of each patient. Patient notes and imaging findings were reviewed to determine the underlying cause of CCI. Results Median National Institute of Health Stroke Scale score was 15 (range 4-27). Mean patient age was 59 years and 90% were men. Two patients were treated with intravenous tissue plasminogen activator (IV tPA) only and three underwent endovascular treatment in both the cerebral and coronary vessels sequentially. One patient underwent percutaneous coronary intervention (PCI) only and two underwent PCI after IV tPA therapy. Two patients were conservatively treated due to poor premorbid status. At the three-month follow-up, five patients had excellent functional outcomes (modified Rankin Scale 0-1) while three died. Conclusion CCI is a rare but devastating clinical scenario, with high incidence of morbidity and mortality. Treatment strategy can impact patient outcome, and further research is warranted on the ideal acute and post-reperfusion treatments for CCI. In this series, IV tPA at stroke doses appeared to be the preferred initial step for its treatment, with subsequent coronary or cerebral endovascular therapy, if necessary.
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Affiliation(s)
- Cheryl Zhiya Chong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Ching-Hui Sia
- Yong Loo Lin School of Medicine, National University of Singapore; Department of Cardiology, National University Heart Centre, Singapore
| | - Thet Khaing
- Department of Cardiology, National University Heart Centre, Singapore
| | - Leonard Leong Litt Yeo
- Yong Loo Lin School of Medicine, National University of Singapore; Division of Neurology, Department of Medicine, National University Health System, Singapore
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Association of 24-hour blood pressure parameters post-thrombectomy with functional outcomes according to collateral status. J Neurol Sci 2022; 441:120369. [DOI: 10.1016/j.jns.2022.120369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 07/07/2022] [Accepted: 07/27/2022] [Indexed: 11/17/2022]
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Blood Pressure Variability Indices for Outcome Prediction After Thrombectomy in Stroke by Using High-Resolution Data. Neurocrit Care 2022; 37:220-229. [PMID: 35606560 PMCID: PMC9343264 DOI: 10.1007/s12028-022-01519-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 04/11/2022] [Indexed: 11/25/2022]
Abstract
Background Blood pressure variability (BPV) is associated with outcome after endovascular thrombectomy in acute large vessel occlusion stroke. We aimed to provide the optimal sampling frequency and BPV index for outcome prediction by using high-resolution blood pressure (BP) data. Methods Patient characteristics, 3-month outcome, and BP values measured intraarterially at 1 Hz for up to 24 h were extracted from 34 patients treated at a tertiary care center neurocritical care unit. Outcome was dichotomized (modified Rankin Scale 0–2, favorable, and 3–6, unfavorable) and associated with systolic BPV (as calculated by using standard deviation, coefficient of variation, averaged real variability, successive variation, number of trend changes, and a spectral approach using the power of specific BP frequencies). BP values were downsampled by either averaging or omitting all BP values within each prespecified time bin to compare the different sampling rates. Results Out of 34 patients (age 72 ± 12.7 years, 67.6% men), 10 (29.4%) achieved a favorable functional outcome and 24 (70.6%) had an unfavorable functional outcome at 3 months. No group differences were found in mean absolute systolic BP (SBP) (130 ± 18 mm Hg, p = 0.82) and diastolic BP (DBP) (59 ± 10 mm Hg, p = 1.00) during the monitoring time. BPV only reached predictive significance when using successive variation extracted from downsampled (averaged over 5 min) SBP data (median 4.8 mm Hg [range 3.8–7.1]) in patients with favorable versus 7.1 mmHg [range 5.5–9.7] in those with unfavorable outcome, area under the curve = 0.74 [confidence interval (CI) 0.57–0.85; p = 0.031], or the power of midrange frequencies between 1/20 and 1/5 min [area under the curve = 0.75 (CI 0.59–0.86), p = 0.020]. Conclusions Using high-resolution BP data of 1 Hz, downsampling by averaging all BP values within 5-min intervals is essential to find relevant differences in systolic BPV, as noise can be avoided (confirmed by the significance of the power of midrange frequencies). These results demonstrate how high-resolution BP data can be processed for effective outcome prediction. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-022-01519-x.
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Regenhardt RW, Bonkhoff AK, Bretzner M, Etherton MR, Das AS, Hong S, Alotaibi NM, Vranic JE, Dmytriw AA, Stapleton CJ, Patel AB, Leslie-Mazwi TM, Rost NS. Association of Infarct Topography and Outcome After Endovascular Thrombectomy in Patients With Acute Ischemic Stroke. Neurology 2022; 98:e1094-e1103. [PMID: 35101908 PMCID: PMC8935439 DOI: 10.1212/wnl.0000000000200034] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 01/03/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The care of patients with large vessel occlusion (LVO) stroke has been revolutionized by endovascular thrombectomy (EVT). While EVT has a large effect size, most patients treated with EVT remain disabled or die within 90 days. A better understanding of outcomes may influence EVT selection criteria, novel therapies, and prognostication. We sought to identify associations between outcomes and brain regions involved in ischemic lesions. METHODS For this cohort study, consecutive patients with LVO who were treated with EVT and underwent post-EVT MRI were identified from a tertiary referral center (2011-2019). Acute ischemic lesions were manually segmented from diffusion-weighted imaging and spatially normalized. Individual lesions were parcellated (atlas-defined 94 cortical regions, 14 subcortical nuclei, 20 white matter tracts) and reduced to 10 essential lesion patterns with the use of unsupervised dimensionality reduction techniques. Ninety-day modified Rankin Scale (mRS) score (>2) was modeled via bayesian regression, taking the 10 lesion patterns as inputs and controlling for lesion size, age, sex, acute NIH Stroke Scale (NIHSS) score, alteplase, prior stroke, intracerebral hemorrhage, and good reperfusion (Thrombolysis in Cerebral Infarction 2b-3). In comparative analyses, 90-day mRS score was modeled considering covariates only, and compartment-wise relevances for acute stroke severity and 90-day mRS score were evaluated. RESULTS There were 151 patients with LVO identified (age 68 ± 15 years, 52% female). The median NIHSS score was 16 (interquartile range 13-20); 56% had mRS score >2. Lesion locations predictive of 90-day mRS score involved bilateral but left hemispherically more pronounced precentral and postcentral gyri, insular and opercular cortex, and left putamen and caudate (area under the curve 0.91, highest probability density interval [HPDI] covering 90% certainty 0.90-0.92). The lesion location model outperformed the simpler model relying on covariates only (bayesian model comparison of 97% weight to the model with vs 3% weight to the model without lesion location). While lesions affecting subcortical nuclei had the highest relevance for stroke severity (posterior distribution mean 0.75, 90% HPDI 0.256-1.31), lesions affecting white matter tracts had the highest relevance for 90-day mRS score (0.656, 90% HPDI 0.0864-1.12). DISCUSSION These data describe the significance for outcomes of specific brain regions involved in ischemic lesions on MRI after EVT. Future work in additional datasets is needed to confirm these granular findings.
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Affiliation(s)
- Robert W Regenhardt
- From the Departments of Neurology (R.W.R., A.K.B., M.B., M.R.E., A.S.D., S.H., T.M.L.-M., N.S.R.), Neurosurgery (R.W.R., N.M.A., J.E.V., A.A.D., C.J.S., A.B.P., T.M.L.-M.), and Radiology (J.E.V., A.A.D.), Massachusetts General Hospital, Harvard Medical School, Boston.
| | - Anna K Bonkhoff
- From the Departments of Neurology (R.W.R., A.K.B., M.B., M.R.E., A.S.D., S.H., T.M.L.-M., N.S.R.), Neurosurgery (R.W.R., N.M.A., J.E.V., A.A.D., C.J.S., A.B.P., T.M.L.-M.), and Radiology (J.E.V., A.A.D.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Martin Bretzner
- From the Departments of Neurology (R.W.R., A.K.B., M.B., M.R.E., A.S.D., S.H., T.M.L.-M., N.S.R.), Neurosurgery (R.W.R., N.M.A., J.E.V., A.A.D., C.J.S., A.B.P., T.M.L.-M.), and Radiology (J.E.V., A.A.D.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Mark R Etherton
- From the Departments of Neurology (R.W.R., A.K.B., M.B., M.R.E., A.S.D., S.H., T.M.L.-M., N.S.R.), Neurosurgery (R.W.R., N.M.A., J.E.V., A.A.D., C.J.S., A.B.P., T.M.L.-M.), and Radiology (J.E.V., A.A.D.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Alvin S Das
- From the Departments of Neurology (R.W.R., A.K.B., M.B., M.R.E., A.S.D., S.H., T.M.L.-M., N.S.R.), Neurosurgery (R.W.R., N.M.A., J.E.V., A.A.D., C.J.S., A.B.P., T.M.L.-M.), and Radiology (J.E.V., A.A.D.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Sungmin Hong
- From the Departments of Neurology (R.W.R., A.K.B., M.B., M.R.E., A.S.D., S.H., T.M.L.-M., N.S.R.), Neurosurgery (R.W.R., N.M.A., J.E.V., A.A.D., C.J.S., A.B.P., T.M.L.-M.), and Radiology (J.E.V., A.A.D.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Naif M Alotaibi
- From the Departments of Neurology (R.W.R., A.K.B., M.B., M.R.E., A.S.D., S.H., T.M.L.-M., N.S.R.), Neurosurgery (R.W.R., N.M.A., J.E.V., A.A.D., C.J.S., A.B.P., T.M.L.-M.), and Radiology (J.E.V., A.A.D.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Justin E Vranic
- From the Departments of Neurology (R.W.R., A.K.B., M.B., M.R.E., A.S.D., S.H., T.M.L.-M., N.S.R.), Neurosurgery (R.W.R., N.M.A., J.E.V., A.A.D., C.J.S., A.B.P., T.M.L.-M.), and Radiology (J.E.V., A.A.D.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Adam A Dmytriw
- From the Departments of Neurology (R.W.R., A.K.B., M.B., M.R.E., A.S.D., S.H., T.M.L.-M., N.S.R.), Neurosurgery (R.W.R., N.M.A., J.E.V., A.A.D., C.J.S., A.B.P., T.M.L.-M.), and Radiology (J.E.V., A.A.D.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Christopher J Stapleton
- From the Departments of Neurology (R.W.R., A.K.B., M.B., M.R.E., A.S.D., S.H., T.M.L.-M., N.S.R.), Neurosurgery (R.W.R., N.M.A., J.E.V., A.A.D., C.J.S., A.B.P., T.M.L.-M.), and Radiology (J.E.V., A.A.D.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Aman B Patel
- From the Departments of Neurology (R.W.R., A.K.B., M.B., M.R.E., A.S.D., S.H., T.M.L.-M., N.S.R.), Neurosurgery (R.W.R., N.M.A., J.E.V., A.A.D., C.J.S., A.B.P., T.M.L.-M.), and Radiology (J.E.V., A.A.D.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Thabele M Leslie-Mazwi
- From the Departments of Neurology (R.W.R., A.K.B., M.B., M.R.E., A.S.D., S.H., T.M.L.-M., N.S.R.), Neurosurgery (R.W.R., N.M.A., J.E.V., A.A.D., C.J.S., A.B.P., T.M.L.-M.), and Radiology (J.E.V., A.A.D.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Natalia S Rost
- From the Departments of Neurology (R.W.R., A.K.B., M.B., M.R.E., A.S.D., S.H., T.M.L.-M., N.S.R.), Neurosurgery (R.W.R., N.M.A., J.E.V., A.A.D., C.J.S., A.B.P., T.M.L.-M.), and Radiology (J.E.V., A.A.D.), Massachusetts General Hospital, Harvard Medical School, Boston
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Prust M, Saylor D, Zimba S, Sarfo FS, Shrestha GS, Berkowitz A, Vora N. Inpatient Management of Acute Stroke of Unknown Type in Resource-Limited Settings. Stroke 2022; 53:e108-e117. [PMID: 35045720 PMCID: PMC8885836 DOI: 10.1161/strokeaha.121.037297] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Stroke is the second leading cause of death and disability worldwide, with a disproportionate burden on low- and middle-income countries. Critical elements of guideline-based stroke care developed in high-income countries are not applicable to resource-limited settings, where lack of access to neuroimaging prevents clinicians from distinguishing between ischemic stroke and intracranial hemorrhage, requiring challenging clinical decision-making, particularly in the acute setting. We discuss strategies for acute inpatient management of stroke of unknown type with a focus on blood pressure management and antiplatelet therapy when neuroimaging is unavailable, and review some of the challenges and strategies for successfully implementing stroke unit care in resource-limited health care settings.
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Affiliation(s)
| | - Deanna Saylor
- Johns Hopkins University Hospital, Baltimore, MD, USA,University Teaching Hospital, Lusaka, Zambia
| | | | | | | | - Aaron Berkowitz
- Kaiser Permanente Bernard J Tyson School of Medicine, Pasadena, CA, USA
| | - Nirali Vora
- Stanford University Medical Center, Stanford, CA, USA
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28
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Bai S, Lu X, Pan Q, Wang B, Pong U K, Yang Y, Wang H, Lin S, Feng L, Wang Y, Li Y, Lin W, Wang Y, Zhang X, Li Y, Li L, Yang Z, Wang M, Lee WYW, Jiang X, Li G. Cranial Bone Transport Promotes Angiogenesis, Neurogenesis, and Modulates Meningeal Lymphatic Function in Middle Cerebral Artery Occlusion Rats. Stroke 2022; 53:1373-1385. [PMID: 35135326 DOI: 10.1161/strokeaha.121.037912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Ischemic stroke is a leading cause of death and disability worldwide. However, the time window for quickly dissolving clots and restoring cerebral blood flow, using tissue plasminogen activator treatment is rather limited, resulting in many patients experiencing long-term functional impairments if not death. This study aims to determine the roles of cranial bone transport (CBT), a novel, effective, and simple surgical technique, in the recovery of ischemic stroke using middle cerebral artery occlusion (MCAO) rat model. METHODS CBT was performed by slowly sliding a bone segment in skull with a special frame and a speed of 0.25 mm/12 hours for 10 days following MCAO. Morris water maze, rotarod test, and catwalk gait analysis were used to study the neurological behaviors, and infarct area and cerebral flow were evaluated during CBT process. Immunofluorescence staining of CD31 and Nestin/Sox2 (sex determining region Y box 2) was performed to study the angiogenesis and neurogenesis. OVA-A647 (ovalbumin-Alexa Fluor 647) was intracisterna magna injected to evaluate the meningeal lymphatic drainage function. RESULTS CBT treatment has significantly reduced the ischemic lesions areas and improved the neurological deficits in MCAO rats compared with the rats in the control groups. CBT treatment significantly promoted angiogenesis and neurogenesis in the brain of MCAO rats. The drainage function of meningeal lymphatic vessels in MCAO rats was significantly impaired compared with normal rats. Ablation of meningeal lymphatic drainage led to increased neuroinflammation and aggravated neurological deficits and ischemic injury in MCAO rats. CBT treatment significantly improved the meningeal lymphatic drainage function and alleviated T-cell infiltration in MCAO rats. CONCLUSIONS This study provided evidence for the possible mechanisms on how CBT attenuates ischemic stroke injury and facilitates rapid neuronal function recovery, suggesting that CBT may be an alternative treatment strategy for managing ischemic stroke.
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Affiliation(s)
- Shanshan Bai
- Department of Orthopaedics & Traumatology, Stem Cells and Regenerative Medicine Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, SAR, PR China (S.B., X.L., B.W., Y.Y., H.W., S.L., L.F., Yan Wang, Yucong Li, W.L., Yujia Wang, X.Z., Yuan Li, L.L., Z.Y., M.W., W.Y.-W.L., G.L.)
| | - Xuan Lu
- Department of Orthopaedics & Traumatology, Stem Cells and Regenerative Medicine Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, SAR, PR China (S.B., X.L., B.W., Y.Y., H.W., S.L., L.F., Yan Wang, Yucong Li, W.L., Yujia Wang, X.Z., Yuan Li, L.L., Z.Y., M.W., W.Y.-W.L., G.L.)
| | - Qi Pan
- Department of Pediatric Orthopaedics, South China Hospital, Health Science Center, Shenzhen University, Shenzhen, PR China (Q.P.)
| | - Bin Wang
- Department of Orthopaedics & Traumatology, Stem Cells and Regenerative Medicine Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, SAR, PR China (S.B., X.L., B.W., Y.Y., H.W., S.L., L.F., Yan Wang, Yucong Li, W.L., Yujia Wang, X.Z., Yuan Li, L.L., Z.Y., M.W., W.Y.-W.L., G.L.)
| | - Kin Pong U
- Key Laboratory for Regenerative Medicine of the Ministry of Education of China, School of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong, SAR, PR China (K.P.U., X.J.)
| | - Yongkang Yang
- Department of Orthopaedics & Traumatology, Stem Cells and Regenerative Medicine Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, SAR, PR China (S.B., X.L., B.W., Y.Y., H.W., S.L., L.F., Yan Wang, Yucong Li, W.L., Yujia Wang, X.Z., Yuan Li, L.L., Z.Y., M.W., W.Y.-W.L., G.L.)
| | - Haixing Wang
- Department of Orthopaedics & Traumatology, Stem Cells and Regenerative Medicine Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, SAR, PR China (S.B., X.L., B.W., Y.Y., H.W., S.L., L.F., Yan Wang, Yucong Li, W.L., Yujia Wang, X.Z., Yuan Li, L.L., Z.Y., M.W., W.Y.-W.L., G.L.)
| | - Sien Lin
- Department of Orthopaedics & Traumatology, Stem Cells and Regenerative Medicine Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, SAR, PR China (S.B., X.L., B.W., Y.Y., H.W., S.L., L.F., Yan Wang, Yucong Li, W.L., Yujia Wang, X.Z., Yuan Li, L.L., Z.Y., M.W., W.Y.-W.L., G.L.)
| | - Lu Feng
- Department of Orthopaedics & Traumatology, Stem Cells and Regenerative Medicine Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, SAR, PR China (S.B., X.L., B.W., Y.Y., H.W., S.L., L.F., Yan Wang, Yucong Li, W.L., Yujia Wang, X.Z., Yuan Li, L.L., Z.Y., M.W., W.Y.-W.L., G.L.)
| | - Yan Wang
- Department of Orthopaedics & Traumatology, Stem Cells and Regenerative Medicine Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, SAR, PR China (S.B., X.L., B.W., Y.Y., H.W., S.L., L.F., Yan Wang, Yucong Li, W.L., Yujia Wang, X.Z., Yuan Li, L.L., Z.Y., M.W., W.Y.-W.L., G.L.)
| | - Yucong Li
- Department of Orthopaedics & Traumatology, Stem Cells and Regenerative Medicine Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, SAR, PR China (S.B., X.L., B.W., Y.Y., H.W., S.L., L.F., Yan Wang, Yucong Li, W.L., Yujia Wang, X.Z., Yuan Li, L.L., Z.Y., M.W., W.Y.-W.L., G.L.)
| | - Weiping Lin
- Department of Orthopaedics & Traumatology, Stem Cells and Regenerative Medicine Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, SAR, PR China (S.B., X.L., B.W., Y.Y., H.W., S.L., L.F., Yan Wang, Yucong Li, W.L., Yujia Wang, X.Z., Yuan Li, L.L., Z.Y., M.W., W.Y.-W.L., G.L.)
| | - Yujia Wang
- Department of Orthopaedics & Traumatology, Stem Cells and Regenerative Medicine Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, SAR, PR China (S.B., X.L., B.W., Y.Y., H.W., S.L., L.F., Yan Wang, Yucong Li, W.L., Yujia Wang, X.Z., Yuan Li, L.L., Z.Y., M.W., W.Y.-W.L., G.L.)
| | - Xiaoting Zhang
- Department of Orthopaedics & Traumatology, Stem Cells and Regenerative Medicine Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, SAR, PR China (S.B., X.L., B.W., Y.Y., H.W., S.L., L.F., Yan Wang, Yucong Li, W.L., Yujia Wang, X.Z., Yuan Li, L.L., Z.Y., M.W., W.Y.-W.L., G.L.)
| | - Yuan Li
- Department of Orthopaedics & Traumatology, Stem Cells and Regenerative Medicine Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, SAR, PR China (S.B., X.L., B.W., Y.Y., H.W., S.L., L.F., Yan Wang, Yucong Li, W.L., Yujia Wang, X.Z., Yuan Li, L.L., Z.Y., M.W., W.Y.-W.L., G.L.)
| | - Linlong Li
- Department of Orthopaedics & Traumatology, Stem Cells and Regenerative Medicine Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, SAR, PR China (S.B., X.L., B.W., Y.Y., H.W., S.L., L.F., Yan Wang, Yucong Li, W.L., Yujia Wang, X.Z., Yuan Li, L.L., Z.Y., M.W., W.Y.-W.L., G.L.)
| | - Zhengmeng Yang
- Department of Orthopaedics & Traumatology, Stem Cells and Regenerative Medicine Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, SAR, PR China (S.B., X.L., B.W., Y.Y., H.W., S.L., L.F., Yan Wang, Yucong Li, W.L., Yujia Wang, X.Z., Yuan Li, L.L., Z.Y., M.W., W.Y.-W.L., G.L.)
| | - Ming Wang
- Department of Orthopaedics & Traumatology, Stem Cells and Regenerative Medicine Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, SAR, PR China (S.B., X.L., B.W., Y.Y., H.W., S.L., L.F., Yan Wang, Yucong Li, W.L., Yujia Wang, X.Z., Yuan Li, L.L., Z.Y., M.W., W.Y.-W.L., G.L.)
| | - Wayne Yuk-Wai Lee
- Department of Orthopaedics & Traumatology, Stem Cells and Regenerative Medicine Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, SAR, PR China (S.B., X.L., B.W., Y.Y., H.W., S.L., L.F., Yan Wang, Yucong Li, W.L., Yujia Wang, X.Z., Yuan Li, L.L., Z.Y., M.W., W.Y.-W.L., G.L.)
| | - Xiaohua Jiang
- Key Laboratory for Regenerative Medicine of the Ministry of Education of China, School of Biomedical Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong, SAR, PR China (K.P.U., X.J.)
| | - Gang Li
- Department of Orthopaedics & Traumatology, Stem Cells and Regenerative Medicine Laboratory, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, SAR, PR China (S.B., X.L., B.W., Y.Y., H.W., S.L., L.F., Yan Wang, Yucong Li, W.L., Yujia Wang, X.Z., Yuan Li, L.L., Z.Y., M.W., W.Y.-W.L., G.L.)
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29
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Arrarte Terreros N, van Willigen BG, Niekolaas WS, Tolhuisen ML, Brouwer J, Coutinho JM, Beenen LFM, Majoie CBLM, van Bavel E, Marquering HA. Occult blood flow patterns distal to an occluded artery in acute ischemic stroke. J Cereb Blood Flow Metab 2022; 42:292-302. [PMID: 34550818 PMCID: PMC8795216 DOI: 10.1177/0271678x211044941] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Residual blood flow distal to an arterial occlusion in patients with acute ischemic stroke (AIS) is associated with favorable patient outcome. Both collateral flow and thrombus permeability may contribute to such residual flow. We propose a method for discriminating between these two mechanisms, based on determining the direction of flow in multiple branches distal to the occluding thrombus using dynamic Computed Tomography Angiography (dynamic CTA). We analyzed dynamic CTA data of 30 AIS patients and present patient-specific cases that identify typical blood flow patterns and velocities. We distinguished patterns with anterograde (N = 10), retrograde (N = 9), and both flow directions (N = 11), with a large variability in velocities for each flow pattern. The observed flow patterns reflect the interplay between permeability and collaterals. The presented method characterizes distal flow and provides a tool to study patient-specific distal tissue perfusion.
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Affiliation(s)
- Nerea Arrarte Terreros
- Department of Biomedical Engineering and Physics,
Amsterdam UMC, location AMC, Amsterdam, the Netherlands
- Department of Radiology and Nuclear Medicine,
Amsterdam UMC, location AMC, Amsterdam, the Netherlands
- Nerea Arrarte Terreros, Department
of Biomedical Engineering and Physics, Amsterdam UMC, location AMC,
Meibergdreef 9, 1011 AZ Amsterdam, the Netherlands.
| | - Bettine G van Willigen
- Department of Biomedical Engineering and Physics,
Amsterdam UMC, location AMC, Amsterdam, the Netherlands
- Cardiovascular Biomechanics, Eindhoven University of
Technology, Eindhoven, the Netherlands
| | - Wera S Niekolaas
- Department of Biomedical Engineering and Physics,
Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Manon L Tolhuisen
- Department of Biomedical Engineering and Physics,
Amsterdam UMC, location AMC, Amsterdam, the Netherlands
- Department of Radiology and Nuclear Medicine,
Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Josje Brouwer
- Department of Neurology, Amsterdam UMC, location AMC,
Amsterdam, the Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC, location AMC,
Amsterdam, the Netherlands
| | - Ludo FM Beenen
- Department of Radiology and Nuclear Medicine,
Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Charles BLM Majoie
- Department of Radiology and Nuclear Medicine,
Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Ed van Bavel
- Department of Biomedical Engineering and Physics,
Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Henk A Marquering
- Department of Biomedical Engineering and Physics,
Amsterdam UMC, location AMC, Amsterdam, the Netherlands
- Department of Radiology and Nuclear Medicine,
Amsterdam UMC, location AMC, Amsterdam, the Netherlands
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30
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Regenhardt RW, Kozberg MG, Dmytriw AA, Vranic JE, Stapleton CJ, Silverman SB, Patel AB. Bow Hunter's Syndrome. Stroke 2022; 53:e26-e29. [PMID: 34865507 PMCID: PMC8849584 DOI: 10.1161/strokeaha.121.037253] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Robert W Regenhardt
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School,Neurology, Massachusetts General Hospital, Harvard Medical School,Corresponding author: 55 Fruit St, Boston, MA, 617-643-2108,
| | - Mariel G Kozberg
- Neurology, Massachusetts General Hospital, Harvard Medical School
| | - Adam A Dmytriw
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School
| | - Justin E Vranic
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School
| | | | | | - Aman B Patel
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School
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Regenhardt RW, González RG, He J, Lev MH, Singhal AB. Symmetric CTA Collaterals Identify Patients with Slow-progressing Stroke Likely to Benefit from Late Thrombectomy. Radiology 2021; 302:400-407. [PMID: 34726532 PMCID: PMC8792270 DOI: 10.1148/radiol.2021210455] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Background Understanding ischemic core growth rate (IGR) is key in identifying patients with slow-progressing large vessel occlusion (LVO) stroke who may benefit from delayed endovascular thrombectomy (EVT). Purpose To evaluate whether symmetric collateral pattern at CT angiography (CTA) can help to identify patients with low IGR and small 24-hour diffusion-weighted MRI ischemic core volume in patients with LVO not treated with reperfusion therapies. Materials and Methods In this secondary analysis of clinical trial data from before EVT became standard of care from January 2007 to June 2009, patients with anterior proximal LVO not treated with reperfusion therapies were evaluated. All patients underwent admission CTA and at least three MRI examinations at four time points over 48 hours. Arterial phase CTA collaterals at presentation were categorized as symmetric, malignant, or other. Diffusion-weighted MRI ischemic core volume and IGR at multiple time points were determined. The IGR at presentation was defined as follows: (ischemic core volume in cubic centimeters)/(time since stroke symptom onset in hours). Multivariable analyses and receiver operator characteristic analyses were used. Results This study evaluated 31 patients (median age, 71 years; interquartile range, 61-81 years; 19 men) with median National Institutes of Health Stroke Scale (NIHSS) score of 13. Collaterals were symmetric (45%; 14 of 31), malignant (13%; four of 31), or other (42%; 13 of 31). Median ischemic core volume was different between collateral patterns at all time points. Presentation was as follows: symmetric, 16 cm3; other, 69 cm3; and malignant, 104 cm3 (P < .001). At 24 hours, median ischemic core volumes were as follows: symmetric, 28 cm3; other, 156 cm3; and malignant, 176 cm3 (P < .001). Median IGR was also different, and most pronounced at presentation: symmetric, 4 cm3 per hour; other, 17 cm3 per hour; and malignant, 20 cm3 per hour (P < .001). After multivariable adjustment, independent determinants of higher presentation IGR included only higher NIHSS (parameter estimate [β = 0.20; 95% CI: 0.05, 0.36; P = .008) and worse collaterals (β = -2.90; 95% CI: -4.31, -1.50; P < .001). The only independent determinant of 24-hour IGR was worse collaterals (β = -2.03; 95% CI: -3.28, -0.78; P = .001). Symmetric collaterals had sensitivity of 87% (13 of 15) and specificity of 94% (15 of 16) for 24-hour ischemic core volume less than 50 cm3 (area under the receiver operating characteristic curve, 0.92; 95% CI: 0.81, 1.00; P < .001). Conclusion In patients with large vessel occlusion not treated with reperfusion therapies, symmetric collateral pattern at CT angiography was common and highly specific for low ischemic core growth rate and small 24-hour ischemic core volume as assessed at diffusion-weighted MRI. After further outcome studies, collateral status at presentation may prove useful in triage for endovascular thrombectomy, especially when MRI and CT perfusion are unavailable. Clinical trial registration no. NCT00414726. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Messina in this issue.
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Affiliation(s)
- Robert W. Regenhardt
- From the Departments of Neurology (R.W.R., A.B.S.), Neurosurgery (R.W.R.), and Radiology (R.G.G., J.H., M.H.L.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, WACC 729C, Boston, MA 02114; Athinoula A Martinos Center for Biomedical Imaging, Charlestown, Mass (R.G.G.); and Mass General Brigham Center for Clinical Data Science, Boston, Mass (R.G.G.)
| | - R Gilberto González
- From the Departments of Neurology (R.W.R., A.B.S.), Neurosurgery (R.W.R.), and Radiology (R.G.G., J.H., M.H.L.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, WACC 729C, Boston, MA 02114; Athinoula A Martinos Center for Biomedical Imaging, Charlestown, Mass (R.G.G.); and Mass General Brigham Center for Clinical Data Science, Boston, Mass (R.G.G.)
| | - Julian He
- From the Departments of Neurology (R.W.R., A.B.S.), Neurosurgery (R.W.R.), and Radiology (R.G.G., J.H., M.H.L.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, WACC 729C, Boston, MA 02114; Athinoula A Martinos Center for Biomedical Imaging, Charlestown, Mass (R.G.G.); and Mass General Brigham Center for Clinical Data Science, Boston, Mass (R.G.G.)
| | - Michael H. Lev
- From the Departments of Neurology (R.W.R., A.B.S.), Neurosurgery (R.W.R.), and Radiology (R.G.G., J.H., M.H.L.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, WACC 729C, Boston, MA 02114; Athinoula A Martinos Center for Biomedical Imaging, Charlestown, Mass (R.G.G.); and Mass General Brigham Center for Clinical Data Science, Boston, Mass (R.G.G.)
| | - Aneesh B. Singhal
- From the Departments of Neurology (R.W.R., A.B.S.), Neurosurgery (R.W.R.), and Radiology (R.G.G., J.H., M.H.L.), Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, WACC 729C, Boston, MA 02114; Athinoula A Martinos Center for Biomedical Imaging, Charlestown, Mass (R.G.G.); and Mass General Brigham Center for Clinical Data Science, Boston, Mass (R.G.G.)
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Young MJ, Regenhardt RW, Sokol LL, Leslie-Mazwi TM. When Should Neuroendovascular Care for Patients With Acute Stroke Be Palliative? AMA J Ethics 2021; 23:E783-793. [PMID: 34859772 PMCID: PMC8684539 DOI: 10.1001/amajethics.2021.783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Noncurative surgeries intended to relieve suffering during serious illness or near end of life have been analyzed across palliative settings. Yet sparse guidance is available to inform clinical management decisions about whether, when, and which interventions should be offered when ischemic stroke and other neurological complications occur in patients whose survival is extended by other novel disease-modifying interventions. This case commentary examines key ethical and clinical considerations in palliative neuroendovascular care of patients with acute stroke.
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Affiliation(s)
- Michael J Young
- Fellow in neurology at Massachusetts General Hospital and Brigham and Women's Hospital in Boston
| | - Robert W Regenhardt
- Neuroendovascular fellow and stroke scientist at Massachusetts General Hospital in Boston
| | - Leonard L Sokol
- Neurology resident physician at Northwestern University in Evanston, Illinois
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Peng TJ, Ortega-Gutiérrez S, de Havenon A, Petersen NH. Blood Pressure Management After Endovascular Thrombectomy. Front Neurol 2021; 12:723461. [PMID: 34539562 PMCID: PMC8446280 DOI: 10.3389/fneur.2021.723461] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 08/12/2021] [Indexed: 11/13/2022] Open
Abstract
Endovascular thrombectomy (EVT) has changed the landscape of acute stroke therapy and has become the standard of care for selected patients presenting with anterior circulation large-vessel occlusion (LVO) stroke. Despite successful reperfusion, many patients with LVO stroke do not regain functional independence. Particularly, patients presenting with extremes of blood pressure (BP) or hemodynamic variability are found to have a worse clinical recovery, suggesting blood pressure optimization as a potential neuroprotective strategy. Current guidelines acknowledge the lack of randomized trials to evaluate the optimal hemodynamic management during the immediate post-stroke period. Following reperfusion, lower blood pressure targets may be warranted to prevent reperfusion injury and promote penumbral recovery, but adequate BP targets adjusted to individual patient factors such as degree of reperfusion, infarct size, and overall hemodynamic status remain undefined. This narrative review outlines the physiological mechanisms of BP control after EVT and summarizes key observational studies and clinical trials evaluating post-EVT BP targets. It also discusses novel treatment strategies and areas of future research that could aid in the determination of the optimal post-EVT blood pressure.
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Affiliation(s)
- Teng J Peng
- Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
| | - Santiago Ortega-Gutiérrez
- Department of Neurology, University of Iowa Carver College of Medicine, Iowa City, IA, United States
| | - Adam de Havenon
- Department of Neurology, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Nils H Petersen
- Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
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Jiang L, Ai Z, Geng W, Chen H, Zhao B, Su H, Yin X, Chen YC. Predictive value of perfusion weighted imaging for early new lesions after stroke patients receive endovascular treatment. Quant Imaging Med Surg 2021; 11:3643-3654. [PMID: 34341738 DOI: 10.21037/qims-21-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 04/09/2021] [Indexed: 11/06/2022]
Abstract
Background Previous studies have focused on early new lesion-associated factors, but the differences in the perfusion status between the at-risk hypoperfusion areas with new lesions and the other hypoperfusion areas in stroke patients before thrombectomy is not clear. We investigated the value of perfusion-weighted imaging (PWI) in predicting early new lesions in patients after stroke. Methods Fifty-five acute stroke patients who underwent diffusion-weighted imaging (DWI) and PWI before and after thrombectomy within 24 h were eligible. The PWI parameters of the core infarct areas (high signal tissue on the DWI), the at-risk hypoperfusion areas (hypoperfusion area with new lesions at follow-up PWI) and the other hypoperfusion areas of patients with new lesions were collected. Statistical analysis was performed to predict new lesions after stroke. The differences in the PWI parameters of the core infarct areas, the at-risk hypoperfusion areas and the other hypoperfusion areas were compared. Receiver operating characteristic (ROC) curve analysis was used to assess the predictive value of the PWI parameters (P<0.05) for the occurrence of new lesions in patients with acute stroke after thrombectomy. Results Fifty-five stroke patients were analyzed, including forty patients (72.73%) with new lesions and fifteen patients (27.27%) without new lesions. Acute stroke patients with new lesions had a longer mean transit time (MTT) and time to peak (TTP) in the at-risk hypoperfusion areas (11.95±3.29; 38.30±11.39) than in the other hypoperfusion areas (8.68±2.08; 29.76±6.86), both of which were significantly different (P<0.0001; P<0.0001, respectively). The ROC analysis showed that the sensitivity and specificity of MTT for predicting the occurrence of new lesions after stroke were 70.00% and 87.50%, respectively; the sensitivity and specificity of TTP were 70.00% and 80.00%, respectively. Conclusions MTT and TTP may be useful in predicting early new lesions in acute stroke patients after thrombectomy.
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Affiliation(s)
- Liang Jiang
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Zhongping Ai
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Wen Geng
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Huiyou Chen
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Boxiang Zhao
- Department of Intervention, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Haobo Su
- Department of Intervention, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Xindao Yin
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yu-Chen Chen
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
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Merli E, Romoli M, Gentile M, Forlivesi S, Borghi AM, Zaniboni A, Simonetti L, Zini A. Bulbar watershed ischemic stroke: the comma-shaped sign-a case series. Neuroradiology 2021; 63:1947-1950. [PMID: 34191099 DOI: 10.1007/s00234-021-02754-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 06/11/2021] [Indexed: 11/28/2022]
Abstract
Watershed infarcts can involve the brainstem, with lesions distributed across the terminal supply from the vertebral and cerebellar arteries. Brain imaging can highlight a comma-shaped lesion at the edge of vertebral and posteroinferior cerebellar artery vascularization territory. Such peculiar MRI lesion shape might suggest a watershed hypoperfusion etiology and direct workup towards causes of hemodynamic impairment, including postural hypotension, cardiac failure, or vertebral artery origin occlusion.
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Affiliation(s)
- Elena Merli
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Neurology and Metropolitan Stroke Center, Maggiore Hospital, Largo Nigrisoli 2, 40133, Bologna, Italy
| | - Michele Romoli
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Neurology and Metropolitan Stroke Center, Maggiore Hospital, Largo Nigrisoli 2, 40133, Bologna, Italy.,Neurology Clinic, S. Maria della Misericordia Hospital - University of Perugia, Perugia, Italy
| | - Mauro Gentile
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Neurology and Metropolitan Stroke Center, Maggiore Hospital, Largo Nigrisoli 2, 40133, Bologna, Italy
| | - Stefano Forlivesi
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Neurology and Metropolitan Stroke Center, Maggiore Hospital, Largo Nigrisoli 2, 40133, Bologna, Italy
| | - Anna Maria Borghi
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Neurology and Metropolitan Stroke Center, Maggiore Hospital, Largo Nigrisoli 2, 40133, Bologna, Italy
| | - Anna Zaniboni
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Neurology and Metropolitan Stroke Center, Maggiore Hospital, Largo Nigrisoli 2, 40133, Bologna, Italy
| | - Luigi Simonetti
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Department of Neuroradiology, Maggiore Hospital, Bologna, Italy
| | - Andrea Zini
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Neurology and Metropolitan Stroke Center, Maggiore Hospital, Largo Nigrisoli 2, 40133, Bologna, Italy.
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Chen M, Wang F, Wang H. Silencing of lncRNA XLOC_035088 Protects Middle Cerebral Artery Occlusion-Induced Ischemic Stroke by Notch1 Signaling. J Neuropathol Exp Neurol 2021; 80:60-70. [PMID: 33236068 PMCID: PMC7749712 DOI: 10.1093/jnen/nlaa129] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Ischemic stroke represents one of the leading causes of mortality worldwide and especially in developing countries. It is crucial for finding effective therapeutic targets that protect the brain against ischemic injury. Long noncoding RNAs (lncRNAs) have emerged as major regulators of neurological diseases, and clarifying their roles in cerebral ischemic injury may provide novel targets for the treatment of ischemic stroke. We aimed to investigate the role of lncRNA-XLOC_035088 in middle cerebral artery occlusion (MCAO)-induced rat brain injury and oxygen-glucose deprivation (OGD)-reperfusion treated hippocampal neurons. In our findings, we found that XLOC_035088 expression was significantly upregulated in OGD-reperfusion treated hippocampal neurons and in different brain regions of MCAO-treated rats. XLOC_035088 silencing protected against MCAO-induced ischemic brain injury in vivo and OGD-induced hippocampal neuronal apoptosis in vitro. Intrahippocampal silencing of XLOC_035088 significantly decreased brain XLOC_035088 expression, reduced brain infarct size, and improved neurological function through inhibiting NOTCH1 following derepression of presenilin 2 (PSEN2). Taken together, this study provides evidence that the lncRNA XLOC_035088/PSEN2/Notch1 axis is involved in the pathogenesis of ischemic brain injury, and presents a promising therapeutic route for ischemic stroke.
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Affiliation(s)
- Miao Chen
- From the Department of Neurology, Shidong Hospital, Affiliated to University of Shanghai for Science and Technology
| | - Feng Wang
- Department of Neurology, Shanghai Seventh People's Hospital, Shanghai University of Traditional Chinese Medicine (FW), Shanghai, PR China
| | - Hairong Wang
- From the Department of Neurology, Shidong Hospital, Affiliated to University of Shanghai for Science and Technology
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Tatebayashi K, Uchida K, Kageyama H, Imamura H, Ohara N, Sakai N, Tanaka K, Yamagami H, Matsumoto Y, Takeuchi M, Morimoto T, Yoshimura S. Differences in Acute Ischemic Stroke Management and Prognosis between Multiple Large-Vessel Occlusion and Single Large-Vessel Occlusion: Subanalysis of the RESCUE-Japan Registry 2. Cerebrovasc Dis 2021; 50:397-404. [PMID: 33756461 DOI: 10.1159/000514369] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 01/02/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The management and prognosis of acute ischemic stroke due to multiple large-vessel occlusion (LVO) (MLVO) are not well scrutinized. We therefore aimed to elucidate the differences in patient characteristics and prognosis of MLVO and single LVO (SLVO). METHODS The Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism Japan Registry 2 (RESCUE-Japan Registry 2) enrolled 2,420 consecutive patients with acute LVO who were admitted within 24 h of onset. We compared patient prognosis between MLVO and SLVO in the favorable outcome, defined as a modified Rankin Scale (mRS) score ≤2, and in mortality at 90 days by adjusting for confounders. Additionally, we stratified MLVO patients into tandem occlusion and different territories, according to the occlusion site information and also examined their characteristics. RESULTS Among the 2,399 patients registered, 124 (5.2%) had MLVO. Although there was no difference between the 2 groups in terms of hypertension as a risk factor, the mean arterial pressure on admission was significantly higher in MLVO (115 vs. 107 mm Hg, p = 0.004). MLVO in different territories was more likely to be cardioembolic (42.1 vs. 10.4%, p = 0.0002), while MLVO in tandem occlusion was more likely to be atherothrombotic (39.5 vs. 81.3%, p < 0.0001). Among MLVO, tandem occlusion had a significantly longer onset-to-door time than different territories (200 vs. 95 min, p = 0.02); accordingly, the tissue plasminogen activator administration was significantly less in tandem occlusion (22.4 vs. 47.9%, p = 0.003). However, interestingly, the endovascular thrombectomy (EVT) was performed significantly more in tandem occlusion (63.2 vs. 41.7%; adjusted odds ratio [aOR], 2.3; 95% confidence interval [CI], 1.1-5.0). The type of MLVO was the only and significant factor associated with EVT performance in multivariate analysis. The favorable outcomes were obtained less in MLVO than in SLVO (28.2 vs. 37.1%; aOR, 0.48; 95% CI, 0.30-0.76). The mortality rate was not significantly different between MLVO and SLVO (8.9 vs. 11.1%, p = 0.42). DISCUSSION/CONCLUSION The prognosis of MLVO was significantly worse than that of SLVO. In different territories, we might be able to consider more aggressive EVT interventions.
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Affiliation(s)
- Kotaro Tatebayashi
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kazutaka Uchida
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan.,Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hiroto Kageyama
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hirotoshi Imamura
- Comprehensive Stroke Center, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Nobuyuki Ohara
- Comprehensive Stroke Center, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Nobuyuki Sakai
- Comprehensive Stroke Center, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Kanta Tanaka
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiroshi Yamagami
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita, Japan.,Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Yasushi Matsumoto
- Department of Neuroendovascular Therapy, Kohnan Hospital, Sendai, Japan
| | | | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan,
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Anadani M, Matusevicius M, Tsivgoulis G, Peeters A, Nunes AP, Mancuso M, Roffe C, de Havenon A, Ahmed N. Magnitude of blood pressure change and clinical outcomes after thrombectomy in stroke caused by large artery occlusion. Eur J Neurol 2021; 28:1922-1930. [PMID: 33682232 DOI: 10.1111/ene.14807] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 02/28/2021] [Accepted: 03/02/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Extremes of both high and low systolic blood pressure (SBP) after mechanical thrombectomy (MT) in large artery occlusion stroke are known predictors of unfavorable outcome. However, the effect of SBP change (∆SBP) during the first 24 h on thrombectomy outcomes remains unclear. We aimed to investigate the association between ∆SBP at different time intervals and thrombectomy outcomes. METHODS We analyzed MT-treated patients registered in the SITS International Stroke Thrombectomy Registry from January 1, 2014 to September 3, 2019. Primary outcome was 3-month unfavorable outcome (modified Rankin scale scores 3-6). We defined ∆SBP as the mean SBP of a given time interval after MT (0-2, 2-4, 4-12, 12-24 h) minus admission SBP. Multivariable mixed logistic regression models were used to adjust for known confounders and center as random effect. Subgroup analyses were included to contrast specific subpopulations. Restricted cubic splines were used to model the associations. RESULTS The study population consisted of 5835 patients (mean age 70 years, 51% male, median NIHSS 16). Mean ∆SBP was -12.3, -15.7, -17.2, and -16.9 mmHg for the time intervals 0-2, 2-4, 4-12 h, and 12-24 h, respectively. Higher ∆SBP was associated with unfavorable outcome at 0-2 h (odds ratio 1.065, 95% confidence interval 1.014-1.118), 2-4 h (1.140, 1.081-1.203), 4-12 h (1.145, 1.087-1.203), and 12-24 h (1.145, 1.089-1.203), for every increase of 10 mmHg. Restricted cubic spline models suggested that increasing ∆SBP was associated with unfavorable outcome, with higher values showing increased risk of unfavorable outcome. CONCLUSION SBP increase after thrombectomy in large artery occlusion stroke is associated with poor functional outcome.
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Affiliation(s)
- Mohammad Anadani
- Department of Neurology, Washington University in St. Louis, St. Louis, MO, USA
| | - Marius Matusevicius
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Research and Education, Karolinska University Hospital, Stockholm, Sweden
| | - Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian University of Athens, Athens, Greece
| | | | - Ana Paiva Nunes
- Stroke Unit Centro Hospitalar Universitário de Lisboa Central - Hospital São José, Lisbon, Portugal
| | - Michelangelo Mancuso
- Department of Clinical and Experimental Medicine, Neurological Clinic, University of Pisa and Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - Christine Roffe
- Stroke Research in Stoke, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Adam de Havenon
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Niaz Ahmed
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurovascular Disease, Karolinska University Hospital, Stockholm, Sweden
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Regenhardt RW, Young MJ, Leslie-Mazwi TM. Is the COVID-19 pandemic magnifying disparities in stroke treatment? J Neurointerv Surg 2021; 13:299-300. [PMID: 33593803 DOI: 10.1136/neurintsurg-2021-017292] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Robert W Regenhardt
- Neurology and Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael J Young
- Neurology and Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Thabele M Leslie-Mazwi
- Neurology and Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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40
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Yu AT, Regenhardt RW, Whitney C, Schwamm LH, Patel AB, Stapleton CJ, Viswanathan A, Hirsch JA, Lev M, Leslie-Mazwi TM. CTA Protocols in a Telestroke Network Improve Efficiency for Both Spoke and Hub Hospitals. AJNR Am J Neuroradiol 2021; 42:435-440. [PMID: 33541900 DOI: 10.3174/ajnr.a6950] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 10/03/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND PURPOSE Telestroke networks support screening for patients with emergent large-vessel occlusions who are eligible for endovascular thrombectomy. Ideal triage processes within telestroke networks remain uncertain. We characterize the impact of implementing a routine spoke hospital CTA protocol in our integrated telestroke network on transfer and thrombectomy patterns. MATERIALS AND METHODS A protocol-driven CTA process was introduced at 22 spoke hospitals in November 2017. We retrospectively identified prospectively collected patients who presented to a spoke hospital with National Institutes of Health Stroke Scale scores ≥6 between March 1, 2016 and March 1, 2017 (pre-CTA), and March 1, 2018 and March 1, 2019 (post-CTA). We describe the demographics, CTA utilization, spoke hospital retention rates, emergent large-vessel occlusion identification, and rates of endovascular thrombectomy. RESULTS There were 167 patients pre-CTA and 207 post-CTA. The rate of CTA at spoke hospitals increased from 15% to 70% (P < .001). Despite increased endovascular thrombectomy screening in the extended window, the overall rates of transfer out of spoke hospitals remained similar (56% versus 54%; P = .83). There was a nonsignificant increase in transfers to our hub hospital for endovascular thrombectomy (26% versus 35%; P = .12), but patients transferred >4.5 hours from last known well increased nearly 5-fold (7% versus 34%; P < .001). The rate of endovascular thrombectomy performed on patients transferred for possible endovascular thrombectomy more than doubled (22% versus 47%; P = .011). CONCLUSIONS Implementation of CTA at spoke hospitals in our telestroke network was feasible and improved the efficiency of stroke triage. Rates of patients retained at spoke hospitals remained stable despite higher numbers of patients screened. Emergent large-vessel occlusion confirmation at the spoke hospital lead to a more than 2-fold increase in thrombectomy rates among transferred patients at the hub.
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Affiliation(s)
- A T Yu
- From the Departments of Neurology (A.T.Y., R.W.R., C.W., L.H.S., A.V., T.M.L.-M.)
| | - R W Regenhardt
- From the Departments of Neurology (A.T.Y., R.W.R., C.W., L.H.S., A.V., T.M.L.-M.)
| | - C Whitney
- From the Departments of Neurology (A.T.Y., R.W.R., C.W., L.H.S., A.V., T.M.L.-M.)
| | - L H Schwamm
- From the Departments of Neurology (A.T.Y., R.W.R., C.W., L.H.S., A.V., T.M.L.-M.)
| | - A B Patel
- Neurosurgery (R.W.R., A.B.P., C.J.S., T.M.L.-M.)
| | | | - A Viswanathan
- From the Departments of Neurology (A.T.Y., R.W.R., C.W., L.H.S., A.V., T.M.L.-M.)
| | - J A Hirsch
- Department of Radiology (J.A.H., M.L.), Massachusetts General Hospital, Boston, Massachusetts
| | - M Lev
- Department of Radiology (J.A.H., M.L.), Massachusetts General Hospital, Boston, Massachusetts
| | - T M Leslie-Mazwi
- From the Departments of Neurology (A.T.Y., R.W.R., C.W., L.H.S., A.V., T.M.L.-M.).,Neurosurgery (R.W.R., A.B.P., C.J.S., T.M.L.-M.)
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de Havenon A, Petersen N, Sultan-Qurraie A, Alexander M, Yaghi S, Park M, Grandhi R, Mistry E. Blood Pressure Management Before, During, and After Endovascular Thrombectomy for Acute Ischemic Stroke. Semin Neurol 2021; 41:46-53. [PMID: 33472269 DOI: 10.1055/s-0040-1722721] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
There is an absence of specific evidence or guideline recommendations on blood pressure management for large vessel occlusion stroke patients. Until randomized data are available, the periprocedural blood pressure management of patients undergoing endovascular thrombectomy can be viewed in two phases relative to the achievement of recanalization. In the hyperacute phase, prior to recanalization, hypotension should be avoided to maintain adequate penumbral perfusion. The American Heart Association guidelines should be followed for the upper end of prethrombectomy blood pressure: ≤185/110 mm Hg, unless post-tissue plasminogen activator administration when the goal is <180/105 mm Hg. After successful recanalization (thrombolysis in cerebral infarction [TICI]: 2b-3), we recommend a target of a maximum systolic blood pressure of < 160 mm Hg, while the persistently occluded patients (TICI < 2b) may require more permissive goals up to <180/105 mm Hg. Future research should focus on generating randomized data on optimal blood pressure management both before and after endovascular thrombectomy, to optimize patient outcomes for these divergent clinical scenarios.
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Affiliation(s)
- Adam de Havenon
- Department of Neurology, University of Utah, Salt Lake City, Utah
| | - Nils Petersen
- Department of Neurology, Yale University, New Haven, Connecticut
| | - Ali Sultan-Qurraie
- Department of Neurology, University of Washington, Valley Medical Center, Seattle, Washington
| | | | - Shadi Yaghi
- Department of Neurology, New York University, New York, New York
| | - Min Park
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Eva Mistry
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
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Lin YH, Tang SC, Chen CH, Lee CW, Lu CJ, Tsai LK, Jeng JS. Angiographic early hyperemia in the middle cerebral artery territory after thrombectomy is associated with favorable clinical outcome in anterior circulation stroke. Eur Radiol 2021; 31:5281-5288. [PMID: 33399907 DOI: 10.1007/s00330-020-07578-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/20/2020] [Accepted: 11/30/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Angiographic cortical early hyperemia (EH) is frequently observed after endovascular thrombectomy (EVT) for large vessel occlusion (LVO) stroke. The aim of the study is to investigate the relationship between EH and clinical outcomes. METHODS Between January 2015 and September 2018, consecutive patients who underwent EVT for anterior circulation LVO stroke with optimal recanalization (modified thrombolysis in cerebral infarction 2b or 3) were included. Angiographic studies after immediate reperfusion were used for analysis for cortical EH sign. Clinical functional outcomes were evaluated with the modified Rankin Scale (mRS) at 90 days. Safety outcomes, including mortality and intracerebral hemorrhage, were assessed. The association of EH between clinical functional and safety outcomes was analyzed. RESULTS A total of 143 patients were analyzed (mean age: 71 years; median National Institutes of Health Stroke Scale score: 18). A positive EH sign was observed in 88 (62%) patients. Good functional outcome at 90 days was significantly different between the EH+ and EH- groups (p = .0157). Intracerebral hemorrhage and mortality did not differ between groups. In multivariate logistic regression analysis, EH was an independent predictor for good clinical outcome (mRS ≤ 2, odds ratio: 3.49, p = .0034) in addition to young age. CONCLUSION Results revealed that the presence of EH is associated with better clinical outcome at 90 days, but not associated with increased hemorrhagic complication. These findings with clinically relevant implications require further validation. KEY POINTS • Angiographic cortical hyperemia is a common finding immediately after endovascular thrombectomy. • Presence of cortical hyperemia is an independent prognostic factor for good clinical outcome. • Hemorrhagic complication is not associated with cortical hyperemia.
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Affiliation(s)
- Yen-Heng Lin
- Department of Medical Imaging, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 10055, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Hao Chen
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chung-Wei Lee
- Department of Medical Imaging, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 10055, Taiwan.
| | - Chi-Ju Lu
- Department of Medical Imaging, National Taiwan University Hospital Yunlin Branch, Douliu City, Yunlin, Taiwan
| | - Li-Kai Tsai
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
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Abstract
The neurological intensive care unit plays an integral role in the management of cerebrovascular disease in the acute and perioperative period. Understanding the use of intracranial pressure (ICP) monitoring and how to apply the appropriate intervention for ICP elevation to ensure adequate cerebral perfusion is the foundation of neurocritical care. Careful management of the interplay between cerebral and systemic physiology, particularly in disorders of cerebral autoregulation, is critical in preventing secondary brain injury. Finally, understanding the cerebral pathophysiology of the underlying injured brain in acute stroke, subarachnoid hemorrhage, and arterial stenosis can help to guide the optimal use of interventional endovascular procedures in these disease states.
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Affiliation(s)
- Vineeta Singh
- Department of Neurology, University of California San Francisco, San Francisco, CA, United States.
| | - Roger Cheng
- Department of Neurology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
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Regenhardt RW, Etherton MR, Das AS, Schirmer MD, Hirsch JA, Stapleton CJ, Patel AB, Leslie-Mazwi TM, Rost NS. Infarct Growth despite Endovascular Thrombectomy Recanalization in Large Vessel Occlusive Stroke. J Neuroimaging 2021; 31:155-164. [PMID: 33119954 PMCID: PMC8365346 DOI: 10.1111/jon.12796] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 09/14/2020] [Accepted: 09/18/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND PURPOSE Endovascular thrombectomy (EVT) has revolutionized large vessel occlusion stroke care. However, not all patients with good endovascular results achieve good outcomes. We sought to understand the clinical significance of magnetic resonance imaging defined infarct growth despite adequate reperfusion and identify associated clinical and radiographic variables. METHODS History, presentation, treatments, and outcomes for consecutive EVT patients at a referral center were collected. Adequate reperfusion was defined as thrombolysis in cerebral infarction (TICI) score 2b-3. Region-specific infarct volumes in white matter, cortex, and basal ganglia were determined on diffusion-weighted imaging. Infarct growth was defined as post-EVT minus pre-EVT volume. Good outcome was defined as 90-day modified Rankin Scale ≤2. RESULTS Forty-four patients with adequate reperfusion were identified with median age 72 years; 64% were women. Each region showed infarct growth: white matter (median pre-EVT 7 cubic centimeters [cc], post-EVT 16 cc), cortex (4 cc, 15 cc), basal ganglia (2 cc, 4 cc), total (20 cc, 39 cc). In multivariable regression, total infarct growth independently decreased the odds of good outcome (odds ratio = .946, 95% CI = .897, .998). Further multivariable analyses for determinants of infarct growth identified female sex was associated with less total growth (β = -.294, P = .042), TICI 3 was associated with less white matter growth (β = -.277, P = .048) and cortical growth (β = -.335, P = .017), and both female sex (β = -.332, P = .015) and coronary disease (β = -.337, P = .015) were associated with less cortical growth. CONCLUSIONS Infarct growth occurred despite adequate reperfusion, disproportionately in the cortex, and independently decreased the odds of good outcome. Infarct growth occurred while patients were hospitalized and may represent a therapeutic target. Potential determinants of region-specific infarct growth were identified that require confirmation in larger studies.
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Affiliation(s)
- Robert W Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School
| | - Mark R Etherton
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School
| | - Alvin S Das
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School
| | - Markus D Schirmer
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School
| | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School
| | | | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School
| | - Thabele M Leslie-Mazwi
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School
| | - Natalia S Rost
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School
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Regenhardt RW, Etherton MR, Das AS, Schirmer MD, Hirsch JA, Stapleton CJ, Patel AB, Leslie-Mazwi TM, Rost NS. White Matter Acute Infarct Volume After Thrombectomy for Anterior Circulation Large Vessel Occlusion Stroke is Associated with Long Term Outcomes. J Stroke Cerebrovasc Dis 2020; 30:105567. [PMID: 33385939 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105567] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 12/15/2020] [Accepted: 12/17/2020] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES Despite the proven efficacy of endovascular thrombectomy (EVT) for large vessel occlusion stroke, over half treated remain functionally disabled or die. Infarct topography may have implications for prognostication, patient selection, and the development of tissue-specific neuroprotective agents. We sought to quantify white matter injury in anterior circulation acute infarcts post-EVT to understand its significance and identify its determinants. MATERIALS AND METHODS Demographics, history, presentations, and outcomes for consecutive patients treated with EVT were recorded in a prospectively maintained database at a single center. Acute infarct masks were coregistered to standard space. Standard atlases of white matter, cortex, and basal ganglia were used to determine region-specific infarct volumes. RESULTS 167 individuals were identified with median age 69 years and 53% women. 85% achieved adequate reperfusion (TICI 2b-3) after EVT; 43% achieved 90-day functional independence (mRS 0-2). Median infarct volumes were 45cc (IQR 18-122) for total, 17cc (6-49) for white matter, 21cc (4-53) for cortex, and 5cc (1-8) for basal ganglia. The odds of 90-day mRS 0-2 were reduced in patients with larger white matter infarct volume (cc, OR=0.89, 95%CI=0.81-0.96), independent of cortex infarct volume, basal ganglia infarct volume, age, NIHSS, and TICI 2b-3 reperfusion. Reperfusion-to-MRI time was associated with white matter infarct volume (hr, β=0.119, p=0.017), but not cortical or basal ganglia infarct volume. CONCLUSIONS These data quantitatively describe region-specific infarct volumes after EVT and suggest the clinical relevance of white matter infarct volume as a predictor of long-term outcomes. Further study is warranted to examine delayed white matter infarction and the significance of specific white matter tracts.
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Affiliation(s)
- Robert W Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, USA; Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, USA.
| | - Mark R Etherton
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, USA
| | - Alvin S Das
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, USA
| | - Markus D Schirmer
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, USA
| | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, USA
| | | | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, USA
| | - Thabele M Leslie-Mazwi
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, USA; Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, USA
| | - Natalia S Rost
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, USA
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Nolan NM, Regenhardt RW, Koch MJ, Raymond SB, Stapleton CJ, Rabinov JD, Silverman SB, Leslie-Mazwi TM, Patel AB. Treatment Approaches and Outcomes for Acute Anterior Circulation Stroke Patients with Tandem Lesions. J Stroke Cerebrovasc Dis 2020; 30:105478. [PMID: 33248344 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105478] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/11/2020] [Accepted: 11/13/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Endovascular thrombectomy (EVT) has revolutionized stroke care for large vessel occlusions (LVOs). However, over half treated remain functionally disabled or die. Patients with tandem lesions, or severe stenosis/occlusion of the cervical internal carotid artery (ICA) with intracranial LVO, may have technical EVT challenges and worse outcomes. We sought to compare treatments and outcomes for patients with anterior circulation tandem lesions versus isolated LVOs. MATERIALS AND METHODS Consecutive tandem lesion and isolated intracranial LVO patients were identified at a single center. Demographics, medical history, presentations, treatments, and outcomes were collected and analyzed. RESULTS From 381 EVT patients, 62 had tandem lesions related to atherosclerosis (74%) or dissection (26%). Compared to isolated intracranial LVOs, they were younger (63 vs 70, p = 0.003), had less atrial fibrillation (13% vs 40%, p < 0.0001), less adequate reperfusion (TICI 2b-3, 58% vs 82%, p < 0.0001), more intracranial hemorrhage (ICH, 13% vs 5%, p = 0.037), but similar 90-day functional independence (mRS 0-2, 34% vs 43%, p = 0.181). The cervical ICA was treated before intracranial EVT (57%), after (13%), not acutely (22%), or was inaccessible (8%). Acute cervical ICA treatments were stenting (57%) or angioplasty alone (13%). Neither acute stenting nor order of treatment was associated with outcomes (TICI 2b-3, ICH, or 90-day mRS 0-2). Among acutely stented, neither alteplase nor antiplatelets were associated with outcomes or stent patency. CONCLUSIONS Tandem lesions were associated with less reperfusion, more ICH, but similar 90-day functional independence. No treatment approach was associated with outcomes. These data illustrate the technical challenges of tandem lesion treatment and underscore the importance of developing new approaches.
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Affiliation(s)
- Neal M Nolan
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Robert W Regenhardt
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA; Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA.
| | - Matthew J Koch
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Scott B Raymond
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA; Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Christopher J Stapleton
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - James D Rabinov
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA; Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Scott B Silverman
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Thabele M Leslie-Mazwi
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA; Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA 02114, USA
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Regenhardt RW, Young MJ, Etherton MR, Das AS, Stapleton CJ, Patel AB, Lev MH, Hirsch JA, Rost NS, Leslie-Mazwi TM. Toward a more inclusive paradigm: thrombectomy for stroke patients with pre-existing disabilities. J Neurointerv Surg 2020; 13:865-868. [PMID: 33127734 DOI: 10.1136/neurintsurg-2020-016783] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/26/2020] [Accepted: 10/04/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Persons with pre-existing disabilities represent over one-third of acute stroke presentations, but account for a far smaller proportion of those receiving endovascular thrombectomy (EVT) and thrombolysis. This is despite existing ethical, economic, legal, and social directives to maximize equity for this vulnerable population. We sought to determine associations between baseline modified Rankin Scale (mRS) and outcomes after EVT. METHODS Individuals who underwent EVT were identified from a prospectively maintained database. Demographics, medical history, presentations, treatments, and outcomes were recorded. Baseline disability was defined as baseline mRS≥2. Accumulated disability was defined as the delta between baseline mRS and absolute 90-day mRS. RESULTS Of 381 individuals, 49 had baseline disability (five with mRS=4, 23 mRS=3, 21 mRS=2). Those with baseline disability were older (81 vs 68 years, P<0.0001), more likely female (65% vs 49%, P=0.032), had more coronary disease (39% vs 20%, P=0.006), stroke/TIA history (35% vs 15%, P=0.002), and higher NIH Stroke Scale (19 vs 16, P=0.001). Baseline mRS was associated with absolute 90-day mRS ≤2 (OR=0.509, 95%CI=0.370-0.700). However, baseline mRS bore no association with accumulated disability by delta mRS ≤0 (ie, return to baseline, OR=1.247, 95%CI=0.943-1.648), delta mRS ≤1 (OR=1.149, 95%CI=0.906-1.458), delta mRS ≤2 (OR 1.097, 95% CI 0.869-1.386), TICI 2b-3 reperfusion (OR=0.914, 95%CI=0.712-1.173), final infarct size (P=0.853, β=-0.014), or intracerebral hemorrhage (OR=0.521, 95%CI=0.244-1.112). CONCLUSIONS While baseline mRS was associated with absolute 90-day disability, there was no association with accumulated disability or other outcomes. Patients with baseline disability should not be routinely excluded from EVT based on baseline mRS alone.
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Affiliation(s)
- Robert W Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA .,Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael J Young
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark R Etherton
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alvin S Das
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher J Stapleton
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael H Lev
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Natalia S Rost
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Thabele M Leslie-Mazwi
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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van den Berg SA, Uniken Venema SM, Mulder MJHL, Treurniet KM, Samuels N, Lingsma HF, Goldhoorn RJB, Jansen IGH, Coutinho JM, Roozenbeek B, Dippel DWJ, Roos YBWEM, van der Worp HB, Nederkoorn PJ. Admission Blood Pressure in Relation to Clinical Outcomes and Successful Reperfusion After Endovascular Stroke Treatment. Stroke 2020; 51:3205-3214. [PMID: 33040702 PMCID: PMC7587243 DOI: 10.1161/strokeaha.120.029907] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose: Optimal blood pressure (BP) targets before endovascular treatment (EVT) for acute ischemic stroke are unknown. We aimed to assess the relation between admission BP and clinical outcomes and successful reperfusion after EVT. Methods: We used data from the MR CLEAN (Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry, an observational, prospective, nationwide cohort study of patients with ischemic stroke treated with EVT in routine clinical practice in the Netherlands. Baseline systolic BP (SBP) and diastolic BP (DBP) were recorded on admission. The primary outcome was the score on the modified Rankin Scale at 90 days. Secondary outcomes included successful reperfusion (extended Thrombolysis in Cerebral Infarction score 2B-3), symptomatic intracranial hemorrhage, and 90-day mortality. Multivariable logistic and linear regression were used to assess the associations of SBP and DBP with outcomes. The relations between BPs and outcomes were tested for nonlinearity. Parameter estimates were calculated per 10 mm Hg increase or decrease in BP. Results: We included 3180 patients treated with EVT between March 2014 and November 2017. The relations between admission SBP and DBP with 90-day modified Rankin Scale scores and mortality were J-shaped, with inflection points around 150 and 81 mm Hg, respectively. An increase in SBP above 150 mm Hg was associated with poor functional outcome (adjusted common odds ratio, 1.09 [95% CI, 1.04–1.15]) and mortality at 90 days (adjusted odds ratio, 1.09 [95% CI, 1.03–1.16]). Following linear relationships, higher SBP was associated with a lower probability of successful reperfusion (adjusted odds ratio, 0.97 [95% CI, 0.94–0.99]) and with the occurrence of symptomatic intracranial hemorrhage (adjusted odds ratio, 1.06 [95% CI, 0.99–1.13]). Results for DBP were largely similar. Conclusions: In patients with acute ischemic stroke treated with EVT, higher admission BP is associated with lower probability of successful reperfusion and with poor clinical outcomes. Further research is needed to investigate whether these patients benefit from BP reduction before EVT.
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Affiliation(s)
- Sophie A van den Berg
- Department of Neurology (S.A.v.d.B., J.M.C., Y.B.W.E.M.R., P.J.N.), Amsterdam University Medical Center, University of Amsterdam, the Netherlands
| | - Simone M Uniken Venema
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, the Netherlands (S.M.U.V., H.B.v.d.W.)
| | - Maxim J H L Mulder
- Department of Neurology (M.J.H.L.M., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Kilian M Treurniet
- Department of Radiology (K.M.T., I.G.H.J.), Amsterdam University Medical Center, University of Amsterdam, the Netherlands
| | - Noor Samuels
- Department of Public Health (N.S., H.F.L.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Hester F Lingsma
- Department of Public Health (N.S., H.F.L.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Robert-Jan B Goldhoorn
- Department of Neurology, Maastricht University Medical Center, Maastricht, the Netherlands (R.-J.B.G.)
| | - Ivo G H Jansen
- Department of Radiology (K.M.T., I.G.H.J.), Amsterdam University Medical Center, University of Amsterdam, the Netherlands
| | - Jonathan M Coutinho
- Department of Neurology (S.A.v.d.B., J.M.C., Y.B.W.E.M.R., P.J.N.), Amsterdam University Medical Center, University of Amsterdam, the Netherlands
| | - Bob Roozenbeek
- Department of Neurology (M.J.H.L.M., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands.,Department of Radiology and Nuclear Medicine (B.R.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Diederik W J Dippel
- Department of Neurology (M.J.H.L.M., B.R., D.W.J.D.), Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Yvo B W E M Roos
- Department of Neurology (S.A.v.d.B., J.M.C., Y.B.W.E.M.R., P.J.N.), Amsterdam University Medical Center, University of Amsterdam, the Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, the Netherlands (S.M.U.V., H.B.v.d.W.)
| | - Paul J Nederkoorn
- Department of Neurology (S.A.v.d.B., J.M.C., Y.B.W.E.M.R., P.J.N.), Amsterdam University Medical Center, University of Amsterdam, the Netherlands
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Anadani M, Lapergue B, Blanc R, Kyheng M, Labreuche J, Machaa MB, Duhamel A, Marnat G, Saleme S, Costalat V, Bracard S, Anxionnat R, Spiotta AM, DeHavenon A, Richard S, Desal H, Mazighi M, Consoli A, Piotin M, Gory B. Admission Blood Pressure and Outcome of Endovascular Therapy: Secondary Analysis of ASTER Trial. J Stroke Cerebrovasc Dis 2020; 29:105347. [PMID: 33017755 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 09/21/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Elevated blood pressure (BP) is common among patients presenting with acute ischemic stroke due to large vessel occlusions. The literature is inconsistent regarding the association between admission BP and outcome of mechanical thrombectomy (MT). Moreover, it is unclear whether the first line thrombectomy strategy (stent retriever [SR] versus contact aspiration [CA]) modifies the relationship between BP and outcome. METHODS This is a post hoc analysis of the ASTER (Contact Aspiration Versus Stent Retriever for Successful Revascularization) randomized trial. BP was measured prior to randomization in all included patients. Co-primary outcomes included 90-day functional independence (modified Rankin Scale [mRS] 0-2) and successful revascularization (modified Treatment in Cerebral Ischemia [mTICI] 2b-3). Secondary outcomes included symptomatic intracerebral hemorrhage (sICH) and parenchymal hemorrhage (PH) within 24 hours. RESULTS A total of 381 patients were included in the present study. Mean (SD) systolic BP (SBP) and diastolic BP (DBP) were 148 (26) mm Hg and 81 (16) mm Hg, respectively. There was no association between SBP or DBP and successful revascularization or 90-day functional independence. Similarly, there was no association between admission SBP or DBP with sICH or PH. Subgroup analysis based on the first-line thrombectomy strategy revealed similar results with no heterogeneity across groups. CONCLUSION Admission BP was not associated with functional, angiographic or safety outcomes. Results were similar in both CA and CA groups.
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Affiliation(s)
- Mohnammd Anadani
- Department of Neurology, Washington University School of Medicine, St Louis, MO, United States.
| | | | - Raphael Blanc
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France.
| | - Maéva Kyheng
- Department of Biostatistics, University Lille, CHU Lille, EA 2694-Santé Publique: Epidémiologie et Qualité des Soins, France.
| | - Julien Labreuche
- Department of Biostatistics, University Lille, CHU Lille, EA 2694-Santé Publique: Epidémiologie et Qualité des Soins, France.
| | - Malek Ben Machaa
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France.
| | - Alain Duhamel
- Department of Biostatistics, University Lille, CHU Lille, EA 2694-Santé Publique: Epidémiologie et Qualité des Soins, France.
| | - Gautier Marnat
- Department of Neuroradiology, University Hospital of Bordeaux, France.
| | - Suzana Saleme
- Department of Interventional Neuroradiology, University Hospital of Limoges, France.
| | - Vincent Costalat
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France.
| | - Serge Bracard
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nancy, Université de Lorraine, INSERM U1254, Nancy, France.
| | - René Anxionnat
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nancy, Université de Lorraine, INSERM U1254, Nancy, France.
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, United States.
| | - Adam DeHavenon
- Department of Neurology, Utah University, Salt lake, UT, United States.
| | - Sébastien Richard
- Department of Neurology, Stroke Unit, University Hospital of Nancy, Université de Lorraine, INSERM U1116, Nancy, France.
| | - Hubert Desal
- Department of Neuroradiology, Guillaume et René Laennec University Hospital, Nantes, France.
| | - Mikael Mazighi
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France.
| | - Arturo Consoli
- Department of Neuroradiology, Foch Hospital, Suresnes, France.
| | - Michel Piotin
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France.
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nancy, Université de Lorraine, INSERM U1254, Nancy, France.
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Bahrani AA, Kong W, Shang Y, Huang C, Smith CD, Powell DK, Jiang Y, Rayapati AO, Jicha GA, Yu G. Diffuse optical assessment of cerebral-autoregulation in older adults stratified by cerebrovascular risk. JOURNAL OF BIOPHOTONICS 2020; 13:e202000073. [PMID: 32533642 PMCID: PMC8824485 DOI: 10.1002/jbio.202000073] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 05/06/2020] [Accepted: 06/09/2020] [Indexed: 05/04/2023]
Abstract
Diagnosis of cerebrovascular disease (CVD) at early stages is essential for preventing sequential complications. CVD is often associated with abnormal cerebral microvasculature, which may impact cerebral-autoregulation (CA). A novel hybrid near-infrared diffuse optical instrument and a finger plethysmograph were used to simultaneously detect low-frequency oscillations (LFOs) of cerebral blood flow (CBF), oxy-hemoglobin concentration ([HbO2 ]), deoxy-hemoglobin concentration ([Hb]) and mean arterial pressure (MAP) in older adults before, during and after 70° head-up-tilting (HUT). The participants with valid data were divided based on Framingham risk score (FRS, 1-30 points) into low-risk (FRS ≤15, n = 13) and high-risk (FRS >15, n = 11) groups for developing CVD. The LFO gains were determined by transfer function analyses with MAP as the input, and CBF, [HbO2 ] and [Hb] as the outputs (CA ∝ 1/Gain). At resting-baseline, LFO gains in the high-risk group were relatively lower compared to the low-risk group. The lower baseline gains in the high-risk group may attribute to compensatory mechanisms to maintain stronger steady-state CAs. However, HUT resulted in smaller gain reductions in the high-risk group compared to the low-risk group, suggesting weaker dynamic CAs. LFO gains are potentially valuable biomarkers for early detection of CVD based on associations with CAs.
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Affiliation(s)
- Ahmed A. Bahrani
- Department of Biomedical Engineering, University of Kentucky, Lexington, Kentucky
- Sanders-Brown Center on Aging, University of Kentucky, Lexington, Kentucky
- Biomedical Engineering Department, Al-Khwarizmi College of Engineering, University of Baghdad, Baghdad, Iraq
| | - Weikai Kong
- Department of Biomedical Engineering, University of Kentucky, Lexington, Kentucky
| | - Yu Shang
- Shanxi Provincial Key Laboratory for Biomedical Imaging and Big Data, North University of China, Shanxi, China
| | - Chong Huang
- Department of Biomedical Engineering, University of Kentucky, Lexington, Kentucky
| | - Charles D. Smith
- Sanders-Brown Center on Aging, University of Kentucky, Lexington, Kentucky
- Magnetic Resonance Imaging and Spectroscopy Center (MRISC), University of Kentucky, Lexington, Kentucky
- Department of Neurology, University of Kentucky, Lexington, Kentucky
| | - David K. Powell
- Magnetic Resonance Imaging and Spectroscopy Center (MRISC), University of Kentucky, Lexington, Kentucky
- Neuroscience Department, University of Kentucky, Lexington, Kentucky
| | - Yang Jiang
- Sanders-Brown Center on Aging, University of Kentucky, Lexington, Kentucky
- Magnetic Resonance Imaging and Spectroscopy Center (MRISC), University of Kentucky, Lexington, Kentucky
- Department of Behavioral Science, University of Kentucky, Lexington, Kentucky
| | - Abner O. Rayapati
- Department of Psychiatry, University of Kentucky, Lexington, Kentucky
| | - Gregory A. Jicha
- Sanders-Brown Center on Aging, University of Kentucky, Lexington, Kentucky
- Magnetic Resonance Imaging and Spectroscopy Center (MRISC), University of Kentucky, Lexington, Kentucky
- Department of Neurology, University of Kentucky, Lexington, Kentucky
| | - Guoqiang Yu
- Department of Biomedical Engineering, University of Kentucky, Lexington, Kentucky
- Correspondence: Guoqiang Yu, Department of Biomedical Engineering, University of Kentucky, Lexington, KY 40506,
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